Self Referral Form
If you have already spoken with us and have been provided with a Grief Encounter (GE/GEX) Code, please enter it here:
GE/GEX:
Your Details
Title:
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Gender:*
Male
Female
Transgender
Non-Binary
Gender Fluid
Gender Queer
Missing data (not recorded/not yet known)
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religious Affilliation:*
Please Select A Value...
Not religious
Agnostic
Baha'i, follower of religion
Buddhist, follower of religion
Christian, follower of religion
Hindu, follower of religion
Jain, follower of religion
Jewish, follower of religion
Muslim, follower of religion
Pagan, follower of religion
Patient religion unknown
Sikh, follower of religion
Zoroastrian, follower of religion
Prefer not to say
Date of Birth:*
If you are aged 14 (or over), we are able to make direct contact. Please provide your contact email or telephone number.
Email:
Mobile Number:
Can we leave a voicemail?
Yes
No
Address Line 1:*
Postcode:*
First Line of Address of Your School/Educational Establishment:*
Postcode of School/Educational Establishment:*
Are you a carer?*
Yes
No
Not Stated
Is there a risk to yourself?*
Yes
No
If yes, please give details:
Parent/ Carer Information
Parent/ Carer Title:*
Parent/Carer First Name:*
Parent/Carer Last Name:*
Parent/Carer Email Address:*
Parent/Carer Phone Number:*
Parent/Carer Date of Birth:*
Deceased Information
First Name of Deceased:*
Last Name of Deceased:*
Age (years) of Person Who Died:*
Person who Died Date of Birth:*
Relationship of person who died to yourself:*
Please Select A Value...
Aunt
Brother
Daughter
Father
Friend
Grand Parent
Grandparent
Husband
Mother
Other
Parent
Partner
Sister
Son
Step Parent
Teacher
Uncle
Person who Died Date of Death:*
Circumstances of Death/ Cause of Death:*
Please Select A Value...
Accidental Death
Cancer or Other Long-term Illness
Covid-19
Dementia
Drowning
Heart Attack/Stroke
Homicide/Murder
Misadventure
Miscarriage
Not Disclosed
Not Yet Known
Organ Failure
Other
Overdose
Road Traffic Accident
Suicide
Terrorism
Health Information
GP Surgery/Practice Name:*
GP Surgery/Practice First Line of Address:*
GP Surgery/Practice Postcode:*
Doctor/ GP Telephone Number:*
Do we have permission to contact your GP?*
Yes
No
Do you have a disability?*
Yes
No
Not Stated
Do you have any special needs we should be aware of?*
Yes
No
If yes, please provide details:
Are any other agencies/services providing support to you?*
Yes
No
If yes, please specify:
Are there any risks or safeguarding concerns?*
Yes
No
If yes, please provide details:
Has there been any additional bereavements?*
Yes
No
If yes, please provide details:
Additional Information
Please tell us a bit more about why you are making this referral:*
Have you received Grief Encounter materials?*
Yes
No
How did you first hear about us?*
Please Select A Value...
Family/Friend
GP/Doctor
Lloyd's Banking Group (Halifax)
Other
Other Charity/Organisation
Place of Worship
School/Education Provider
Scottish Widows
Search Engine (e.g. Google)
Social Media
Social Services
Support After Suicide Partnership (SASP)
Would you like us to provide you with information about all other Grief Encounter activities such as family days and workshops, fundraising events, newsletters and media activity?*
Yes
No
By submitting this form, I confirm I have read and agree to Grief Encounter's Data and Privacy Policy. Data provided will be stored on Grief Encounter’s computer storage system.*
Yes
www.griefencounter.org.uk/privacy/
Please contact contact@griefencounter.org.uk should you have any questions
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