Kent Bereavement | Kent & Medway eReferral

Kent & Medway eReferral

PLEASE NOTE: CHUMS is not an urgent mental health response service. If you, a child or young person are at immediate risk to themselves or others, please contact your GP or local A&E. Alternatively, you can call NHS 111 - Option 2 for Mental Health Crisis support - available 24 hours, 7 days a week.

To help us fully understand the circumstance for which support is required, please answer all the questions below with as much detail as possible. Please ensure that you have consent to share this information with us.

PLEASE READ BEFORE SUBMITTING REFERRAL: If you wish to retain a copy of the information you have provided in this referral for your records, please use the print option from your browser before clicking the submit button below. Once you have submitted the referral you will receive a confirmation with a reference number for your records.

Please make sure you have read the referral criteria before making your referral.

The Information below is for the Person being referred for support:

* Indicates a required field

Person Requiring Support

Title

First Name, as shown on birth certificate *

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Surname, as shown on birth certificate *

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Known as, if different from above

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Date of Birth *

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 *

Unknown or No Fixed Abode

Consent for Post

Telephone Numbers for Referred (if applicable)

Mobile number *

Consent to call Mobile

Mobile voicemail consent

May we contact you by SMS / text messages?

Home number

Consent to call Home

Work number

Consent to call Work

Email Address for Referred (if applicable)

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Email consent

Gender *

Gender at birth, if different from above

Ethnic Origin *

Nationality *

Religion

School/Educational Establishment

GP Surgery *

Do you give consent for your GP to be contacted?

Accessibility

Preferred Language *

Interpreter Required *

Yes

Disability - Please specify: *

Do you require communication in any other format: i.e. Braille, British Sign Language, Makaton etc?

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Is the Referred known to social care or any other organisation? *

Yes

If Yes, please specify:

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Please note: we accept referrals when the recent bereavement has occurred no less than 6 months ago

Please provide details of the deceased, including the relationship to the referred, the cause of death and date. If there are multiple deaths, please provide as much information as possible. *

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Please include the information about how the death(s) have impacted the referred, difficulties they are experiencing, what they witnessed (if able to share), duration of difficulties etc. *

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If the referred person is experiencing trauma and exhibits/expresses trauma symptoms i.e., flashbacks, hypervigilance, avoidance, please include details here: *

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Contact in Case of Emergency

Emergency Contact Name *

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Relationship to Referred *

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Contact telephone number *

Contact email address

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Information for referrer to complete (including self):

Does the referred person understand why they are being referred to CHUMS? *

Yes

Risk

Is the referred person at risk of harm? (e.g. behaviours that are risk to themselves or others, self harm, suicidal ideation, risk of harm from others) *

Yes

Where risk has been identified, give the details of risk and how this is being managed

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Referrer Information (if not self)

First Name of Referrer

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Surname of Referrer

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Relationship to Referred - Please specify

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Referrer Contact Telephone No:

Referrer Contact Email Address:

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Referrer Address:

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Organisation (if applicable)

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Parent/Carer Name (if not referrer)

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Relationship to Referred - please specify

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Parent/Carer Contact Telephone No:

Parent/Carer Contact Email address:

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Parent/Carer Address (if different from referred)

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Unknown or No Fixed Abode

I accept terms and conditions. *

If you have any difficulties filling in this form, please contact CHUMS on:

Contact Telephone: 01622 427300

Contact Email: info@chums.uk.com