Bereavement Service Referral Form

We accept referrals for adults bereaved by the loss of someone with a diagnosed life-limiting illness. Please complete all sections. Incomplete referrals will be returned to the referrer.

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Last updated: 30th August 2023

Consent

Has the client consented to this referral?

Please note this referral will only be processed if the client is aware and has given consent

Client details

Title

Last name

First name

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Phone

Consent to leave a message

Mobile

Consent to leave a message

DOB

Sex

Ethnicity

Language

Marital status

Is the client housebound?

Does the client live alone?

Next of kin/ carer details

Title

First name

Last name

Relationship

Phone

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Referrer

GP/ other services involved

GP name

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Phone

Fax

Other services

Phone

Other services

Phone

Nature of bereavement

We accept referrals for adults bereaved by the loss of someone with a diagnosed life-limiting illness

Date of loss

Relationship to client

Circumstances of death

Bereavement is a normal process and does not usually require intervention. Why do you feel this would be helpful for this client?

Mental health

Please note: If this client has a diagnosed mental health illness, or has multiple issues in addition to bereavement; it is more appropriate they be referred to IAPT/Thinking Ahead or another specialist psychotherapy service.

Is the client under care of a Psychiatrist:

Currently

Previously

Psychiatrist name

Phone

Address line 1

Address line 2

Town/ city

County

Country

Postcode

Are Mental Health Services involved?

Please give as much detail as possible along with contact details

Any other psychological history? Previous counselling

Please give as much detail as possible

Risk

Risk of self-harm?

Risk to others?

Please give as much detail as possible

Medication

Is patient/client prescribed medication for anxiety and/or depression?

Person completing referral

Print name

Signiture

Designation

Phone

Date

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Please complete ALL sections to avoid delays in processing this referral.

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Bereavement Service Referral Form

Want to download the form instead?

Consent

Client details

Next of kin/ carer details

Referrer

GP/ other services involved

Nature of bereavement

Mental health

Risk

Medication

Person completing referral