Bereavement Counselling Referral Form Hospice Care Referral Form | Teesside Hospice

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Need Some Support?

Step 1: Personal Details

Are you the person seeking counselling or are you acting for someone else?

Referrer's Details

Please complete this section if you are referring another person. Please note: you must obtain the consent of the person you are referring for us to process the referral.

Your First Name

Your Last Name

Your Contact Number

Your Email Address

Your Relationship / Organisation

Have you Obtained the Consent of the Person to Make This Referral?

Client's Details

First Name

Last Name

Date of Birth

Address

Contact Number

NHS Number (10 Digits)

Email Address

Gender

Preferred Method of Contact

Consent for Contact

May we contact you via post?

May we leave a voicemail?

May we send a text message?

May we contact you via email?

Our service doesn't provide counselling for children under 7 years old. We feel that children under 7 are best supported by their parent or carer. We recommend that you have a look at the following links that will help you to know how to best to talk to and support a younger child dealing with a bereavement

https://www.childbereavementuk.org/telling-a-child-that-someone-has-died

https://www.childbereavementuk.org/sudden-death-including-accidents-suicide-and-homicide

https://www.childbereavementuk.org/supporting-bereaved-children-and-young-people

Child Bereavement UK also have a helpline you can ring 0800 02 888 40

This website has lots of useful advice and some reasonably priced resources you can buy to help you help a child:

https://shop.winstonswish.org/