Professional referral | Hertfordshire and West Essex Suicide Bereavement Service referral form for professionals

Hertfordshire and West Essex Suicide Bereavement Service referral form for professionals

You have now entered the referral form for professionals. To help us fully understand the problem that you are experiencing please answer all the questions as clearly and fully as you are able to. Before completing the information please ensure that you have the permission of the young person or their parent/carer to share this information with us.

If you are having difficulty with any of the questions or would rather speak to someone directly please call 03300 581653 during office hours (9am to 5pm).

If you wish to retain a copy of the information you have provided in this referral please use the print option from your browser.

* Indicates a required field

Details of person being referred

First Name *

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Surname *

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Date of Birth (DD/MM/YYYY) *

Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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Postcode *

Ethnicity

Gender *

GP Practice

School (if applicable)

Referring Organisation *

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Job Title of Referrer

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Contact Number of Referrer

Referrer Email

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Next of Kin *

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Parent/Carer Address (if applicable)

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Parent/Carer Email Address (if applicable)

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Parent/Carer Mobile Number

We will contact you via SMS text message to provide therapy appointments and reminders. Do you agree for us to contact you in this way?

Yes

Any additional information:
• Name of person dead by suicide
• Date of Suicide
• Any dependants *

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Risk

Are you aware of any risks? (eg behaviours that are a risk to themselves/others such as self-harm, suicidal ideation, substance use and information about if you believe them to be at risk from others)

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Where risks have been identified, how are these currently being managed?

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Any other relevant information?

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I accept terms and conditions. *

Please note that CHUMS is not an Emergency Service and is not able to respond to this form urgently. Therefore, if there are any immediate risks identified or emergency care required please seek immediate advice from your GP/A&E.

Contact Telephone: 03300 581653

Contact Email: info@chums.uk.com