Referral Form

Date of referral

Name of deceased child/young person

Any information available

Known details regarding the cause and circumstances of death(Please consider where young person died, how young person died, when young person died, what happened)

Name of bereaved person(s) to refer

Contact number(s) of bereaved person to refer

Address(es) of bereaved person(If known)

Family details(Please consider any siblings, are parents together, any other individuals to consider)

Memory box given?
—Please choose an option—Yes, 2Wish memory box givenYes, a different memory box has been givenNo, a memory box has not been given

Has verbal consent for referral been given by bereaved individuals being referred?
—Please choose an option—YesNo

Has the bereaved person been informed about the PRUDiC/CDOP?

Name of police officer supporting family?

Contact details of police officer supporting family?

Is there or has there ever been any risk of the following...

Are you aware of any safeguarding issues that can affect us when we visit families in their homes?
YesNo
If yes, please provide details:

Domestic violence:
YesNo
If yes, please provide details:

Mental health services:
YesNo
If yes, please provide details:

Drug and alcohol services:
YesNo
If yes, please provide details:

History of criminal offences:
YesNo
If yes, please provide details:

Ongoing support from other agencies:
YesNo
If yes, please provide details:

Please add any background information you think would be useful to us.For example, additional learning needs, physical/sensory, preferred language