Echoes support referral form (external)

Eligibility Criteria: Momentum Children’s Charity provides support to families through the heartbreak of losing their child (0-18yrs). In addition to families we are already we supporting, we can also take referrals as part of end of life care, sudden loss or suicide. We will be there to help in every way we can. We aim to contact families within 2 working days of referral.

Please note all referrals must be made with the consent of the family.

Patient details

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Ethnicity (optional, please select as appropriate)

School

Cause of Death(Required)

RIP Date(Required)

Hospital(Required)

If you selected 'Other,' please specify below:

Primary carer details

Name(Required)

First Last

Relationship to Patient(Required)

Gender(Required)

Ethnicity (optional, please select as appropriate)

Address line 1(Required)

Address line 2

City(Required)

County(Required)

Postcode(Required)

Email(Required)

Preferred contact number(Required)

Can they communicate in English?(Required)

If 'no' note language spoken

Other carer details. Please leave blank if N/A

Name

First Last

Relationship to Patient

Gender

Ethnicity (optional, please select as appropriate)

Address if different from primary Carer (incl. County)

Postcode

Preferred contact number

Sibling details: Please leave blank if N/A

Sibling 1 – Name

First Last

Sibling 1- Date of birth

Sibling 1 – Gender

Ethnicity (optional, please select as appropriate)

Is in receipt of free school meals or pupil premium

Yes

Sibling 2 – Name

First Last

Sibling 2- Date of birth

Sibling 2 – Gender

Ethnicity (optional, please select as appropriate)

Is in receipt of free school meals or pupil premium

Yes

Sibling 3 – Name

First Last

Sibling 3- Date of birth

Sibling 3 – Gender

Ethnicity (optional, please select as appropriate)

In receipt of free meals or pupil premium

Yes

Reason for referral: To offer the family the most appropriate support, please answer the following brief questions. This information will be used to monitor how our support meets the family’s needs:

Reason for referral to Momentum Children's Charity?

What impact is the bereavement having on the family?

Are there any other agencies/charities supporting the family? If known, please provide details.

Are there any health safety or safeguarding issues that we need to consider when supporting this family** e.g. Safeguarding or safety plans, Drug/Alcohol Issues/Misuse

Declaration- I declare that the above information is accurate:

Parent/Guardian signature to confirm they agree to referral (where a signature cannot be obtained, please note that verbal consent has been gained):(Required)

Have you discussed this referral with the family?(Required)

Yes

Date(Required)

Referrer Signature(Required)

Referrer Name(Required)

Job Title(Required)

Refferal Hospital/Organisation(Required)

If you selected 'Other,' please specify below:

Email(Required)

Contact number(Required)

Date(Required)

Any queries please call 020 8974 5931 to speak to the Family Support Team

The information in this document is confidential and will be held in strict confidence. It will not be used for any purpose other than the evaluation of this product. No part of the document may be circulated, quoted, or reproduced for distribution outside the organisation without prior written approval from the patient/guardian.