Make a Referral to the Forget Me Not Centre for a Child or Young Person

Parent/Guardian

Please enter your details

Your name(Required)

Your relationship to young person(s) being referred(Required)

Telephone number(Required)

Alternative telephone number

Email(Required)

Address(Required)

Street Address Post Code

What is your preferred method of contact?(Required)

By email

By phone

By any means

1st Child/Young Person Being Referred

Please enter the details of the first child being referred (subsequent children/young persons can be added after this)

Their name(Required)

Their age(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Does the child/young person know of this referral?(Required)

Yes

No

Are there any other children to be added to this referral?(Required)

Yes

No

2nd Child/Young Person Being Referred

Please enter the details of the second child being referred (subsequent children/young persons can be added after this)

Their name(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Does the child/young person know of this referral?(Required)

Yes

No

Are there any other children to be added to this referral?(Required)

Yes

No

3rd Child/Young Person Being Referred

Please enter the details of the third child being referred (subsequent children/young persons can be added after this)

Their name(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Does the child/young person know of this referral?(Required)

Yes

No

Are there any other children to be added to this referral?(Required)

Yes

No

4th Child/Young Person Being Referred

Please enter the details of the fourth child being referred

Their name(Required)

Date of birth(Required)

Gender(Required)

Male

Female

Non-binary

Prefer not to say

Does the child/young person know of this referral?(Required)

Yes

No

Loved one

Information regarding your loved one and their relationship with the child(ren)/young person(s) listed on this referral

Their name(Required)

Their relationship to young person(s)(Required)

Diagnosis

Date of death (if applicable)

Did your loved one receive care from St John's Hospice?(Required)

Yes, on the in-patient ward

Yes, through Hospice at Home

No

Has the child(ren)'s family got any links with His Majesty's Armed Forces (Army, Navy, RAF) or Merchant Navy?

Yes

No

I'm not sure

Please provide details (e.g. veteran/still serving and who they are in relation to the child(ren))

Any other information

Name of GP(Required)

Address of GP(Required)

GP Contact Number(Required)

Please give details of school/college that your child/children attend(Required)

Named person to contact in school(Required)

If your child has a behaviour management plan, please include details below

Comments

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Make a Referral to the Forget Me Not Centre for a Child or Young Person

Forget Me Not Centre Referral for Bereavement Support

Parent/Guardian

1st Child/Young Person Being Referred

2nd Child/Young Person Being Referred

3rd Child/Young Person Being Referred

4th Child/Young Person Being Referred

Loved one

Welcome

I Need Help Now

I need palliative care for a relative, friend, myself or a patient.

Myself a friend or relative has been referred to St John’s for care and I need to know more.

I am currently experiencing a bereavement and I need help.

Where does St John’s Hospice offer its services?

I have a fundraising or event enquiry.

I would like to donate to St John’s Hospice.

Contact Information