Refer to 565 Service

If you are seeking bereavement support for your child, the 565 Service is here.

To refer a child for emotional support if a relative has a progressive or life-limiting illness, and is known to the hospice, please contact us on 0300 303 5196 and a member of the team will take the relevant details over the phone. Alternatively, click the button below to refer online.

The 565 service is available to children and young people who live in the East Suffolk area who are mourning a loss from a progressive or life-limiting condition.

This includes conditions such as cancer, heart failure, kidney disease, MND, MS, Parkinson’s disease, Dementia or COVID-19.

Unfortunately, we do not currently have a children and young people’s service in Great Yarmouth and Waveney.

Please call us if you’d like to discuss further.

565 Service Bereavement Referral Form

"*" indicates required fields

Step 1 of 9

Please confirm the below to start the referral to our 565 Service:

I can confirm that the deceased person was living with a progressive disease, life-limiting condition or COVID-19.*

Yes, I can confirm this is true

E.g. cancer, heart failure, kidney disease, MND, MS, Parkinson’s disease, Dementia

What illness or condition did the deceased person die from?*

Are you referring yourself or on behalf of someone?*

Details of the child/young person being referred

Please give the full name of the child/young person seeking support:*

First Last

Please detail your role/relationship in relation to the child/young person being referred:*

What are their preferred pronouns?*

He/Him

She/Her

They/Them

Other

Please enter pronouns, if not listed above

Please give the date of birth of the person being referred:*

Please enter the child/young person's address:*

Street Address Address Line 2 City County Postcode Country

Please enter your name:*

First Last

Address:*

Street Address Address Line 2 City County Postcode Country

Do you live at this address too?*

Yes

Does the parent/carer live at the same address as the child/young person?*

Yes

If no, please detail the different address below:

Street Address Address Line 2 City County Postcode Country

Please detail the parent/carer name:*

First Last

Please detail the parent/carer's relationship to the child:*

Parent/carer contact telephone number:

Reason for the referral

Reason for referral*

Detail issues or concerns that have prompted this referral (e.g. difficulties processing loss, anger, low mood, difficulties sleeping, poor school attendance). How the deceased died (e.g. terminal illness, cancer, COVID-19). How do you think our service can support you?

Name of the deceased:*

First Last

Relationship to the deceased:*

Relationship of child/young person to the deceased:*

Deceased date of birth:

Deceased date of death:

Place of death:*

Were they known to any hospice or a specialist palliative care team?*

If yes, detail which hospice:*

Our criteria

565 Service Bereavement Referral Form

Please confirm the below to start the referral to our 565 Service:

Consent & responsibility

Details of the child/young person being referred

Your details

Reason for the referral

Accessibility & inclusion requirements

Additional support

Final stage of referral

Refer to 565 Service

Our criteria

565 Service Bereavement Referral Form

Please confirm the below to start the referral to our 565 Service:

Consent & responsibility

Details of the child/young person being referred

Your details

Reason for the referral

Accessibility & inclusion requirements

Additional support

Final stage of referral

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