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Refer to LivingGrief

Make a Referral to LivingGrief

You can make a referral to our LivingGrief bereavement by filling in the form on the bottom of this page.

Call LivingGrief: 0300 303 5196 (Mon-Fri, 9am-4pm) Email the team

Our referral criteria

Please note, different catchment areas have different criteria for referrals:

If you live in Great Yarmouth & Waveney, we support people who are already known to St Elizabeth East Coast Hospice & who are aged 18 and over.
If you live in East & Mid-Suffolk, we accept referrals from anyone grieving a loss from a progressive or life-limiting illness. You do not have to be known to the hospice. This includes conditions such as cancer, heart failure, kidney disease, MND, MS, Parkinson’s disease, dementia or COVID-19.

Make a Referral

Further support

LivingGrief Hub

If you have a bereavement from a different cause. such as loss of a baby, child, adult or suicide, visit our LivingGrief Hub website to be signposted to tailored support for your grief.

As well as specific services, there are social support groups within Ipswich, Stowmarket, Woodbridge, Felixstowe & Eye.

Refer to 565 Service for Children Support

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

Unfortunately, we do not currently have a children and young people’s service in Great Yarmouth and Waveney. Please call us on 0300 3035196 if you’d like to discuss further.

LivingGrief Referral Form

Please fill in this referral form to request support for your bereavement. If you are unsure of your catchment area, please call our team on 0300 303 5196, Monday to Friday. 9am-4pm.

"*" indicates required fields

Step 1 of 8

12%

What catchment area do you live in?

East & Mid-Suffolk

Great Yarmouth & Waveney

If you are unsure on your catchment area, please call us on 0300 3035196.

Where did you hear about this service?

Please detail how you heard about the 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

I can confirm that the deceased person was known to St Elizabeth Hospice and received care from the palliative care team*

Yes, I can confirm this is true

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

Are you referring yourself or on behalf of someone?*

If you are referring someone else, has the referred consented to the referral?

If they have not consented, please detail why:

If you are referring someone else, please detail your relationship to them

If you are referring someone else please detail your full name:

If you are referring someone else, please detail your contact telephone number:

Full name of bereaved individual seeking support*

Preferred pronouns of person being referred*

He/Him

She/Her

They/Them

Other

Please enter their pronouns, if not listed above

Your full name*

Preferred pronouns*

He/Him

She/Her

They/Them

Other

Please enter your preferred pronouns, if not listed above:

Date of birth*

Day

Month

Year

Address*

Street Address Address Line 2 City County Postcode Country

Primary phone number of bereaved person seeking support*

Email address of bereaved person seeking support*

Preferred method of written contact*

Post

Ethnicity of person being referred*

Gender of person being referred*

Primary Language*

Religion

Do you consider yourself/the person being referred to have a disability?*

If yes, please tell us if you/the person being referred requires any access support

Reason for referral*

Detail issues or concerns that have prompted this referral and how the deceased died (e.g. terminal illness, cancer, COVID-19)

Name of deceased*

Relationship to deceased*

Deceased date of birth:

Day

Month

Year

Date of death:

Day

Month

Year

Place of death:*

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

If yes, detail which hospice

Are you/the bereaved receiving care, support or treatment from any other organisation or healthcare professional for this bereavement or any other mental health concern?*

For example, anxiety

If yes, please give details including name/address/telephone numbers of support services you use

For example, mental health service. If so, please give details e.g. name, address, telephone numbers

Is there anyone else in the family that has been referred to our service?

Yes

Unsure

If yes, please let us know their name(s):

Self-Assessment

This final section is a self-assessment which must be completed to submit your referral.

1. Are you able to complete the self-assessment?*

Yes, I will complete this myself

I am a professional referring on somebody’s behalf and unable to complete the self-assessment

I am filling in this form on behalf of a family member and they are unavailable to answer the self-assessment

2. I feel able to face the pain which comes with loss*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

3. For me, it is difficult to switch off thoughts about the person I have lost*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

4. I feel very aware of my inner strength when faced with grief*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

5. I believe that I must be brave in the face of loss*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

6. I feel that I will always carry the pain of grief with me*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

7. For me, it is important to keep my grief under control*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

8. Life has less meaning for me after the loss*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

9. For me, it’s best to avoid thinking about my loss*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

10. It may not always feel like it but I do believe that I will come through this experience of grief*

Strongly agree

Agree

Neither agree or disagree

Disagree

Strongly disagree

Can you tell us about your bereavement? Tell us about what is most difficult for you? E.g. loneliness, nightmares, low mood

Did you witness any particularly distressing events that continue to trouble you?

For how long had the person been ill? Have you previously suffered any other significant losses?

What helps you to manage at the current time? Do you have support from friends and family?

Can you please tell us if you are currently on any medication, or coping with any ongoing mental or physical health issues?

Do you have any previous mental or physical health conditions that you would be happy to share with us or may be important for us to know?

Are there any other issues, comments or events that you feel it would be helpful for us to know about?

We offer support/counselling via a number of routes. Please tick all options you are interested in:

Telephone

Online (Zoom or Teams)

Face to face – individual

Face to face – group support

Art therapy

Music therapy

For face to face support, which location is best for you? Tick all that apply:

Ipswich

Stowmarket (Fri)

Felixstowe (Tues mornings)

Lowestoft (Tues)

Beccles (Mon, Tues, Weds, Thurs)

Gorleston (Tues or Thurs)

Counselling operates between 9am and 5pm, Monday to Friday. Please let us know your availability and any factors we need to be aware of eg. within school hours, shift patterns*

We are currently assessing if there is a need for online groups. Please select if you would prefer an online group, should this be available:

Yes, I would like online groups to be an option

No I am not interested

Please add any further comments:

Make a Referral to LivingGrief

Our referral criteria

Further support

LivingGrief Referral Form

Self-Assessment

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