Parent/Carer referral | Hertfordshire and West Essex Suicide Bereavement Service referral form for parents/carers (Demo)

You have now entered the referral form for parents and carers. 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.

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.

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First Name of Child*

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Last Name of Child*

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Date of Birth of Child (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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Post Code*

Ethnicity of Child*

Gender of Child*

School*

GP Practice*

Can we contact this GP surgery?*

Yes

Parent/Carer Name*

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Relationship to child*

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Parent/Carer Address*

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Preferred Phone Number*

Please indicate if we may leave a message on your preferred number*

Yes

Email Address*

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I have parental responsibility for this child and give my consent to CHUMS to work with them. *

Yes

Name of anyone else with parental Responsibility

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Their address

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Their contact number

Relationship to child

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Any additional information:*

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What is the understanding of the child of the referral to CHUMS?*

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Is your child known to social care or any other organisations?*

Yes

If yes, who?

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Do you give consent for us to contact these other agencies?

Yes

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. *

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Terms and conditions

Please tick the checkbox to accept the terms and conditions.

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