Child Bereavement Referral

Intro

Please complete this form if you are the child/young person's parent or guardian, and would like to access our bereavement service for your child, following the loss of a loved one who was under the care of St Luke's. If you have any questions please call 0114 235 7656.

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Name of person completing this form

Are you the child/young person's parent or guardian?

Yes

Other

What is your relation to the child/young person?

We can only accept a referral if consent has been given. Does the child's parent/guardian and the child consent to this referral?

Yes

Does the child / young person know that you are making this referral? Are they in agreement?

Yes

Other

Please expand

Child/young person's full name

Child/young person's date of birth

Child/young person's address, including postcode

Address of parent/guardian (if different to above), including postcode

Contact number of parent/guardian

Email address of parent/guardian

Name of patient who received care from St Luke's Hospice

Child/young person's relationship to patient known to St Luke's Hospice

Date of birth of patient known to St Luke's Hospice (if known)

Consent for storing submitted data

Yes, I give permission to store and process my data

Catpcha

Children's Bereavement Service Referral Form

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