Adult Bereavement Services Referral

Name: Highland Hospice
Price range: $

Criteria: Highland Hospice Adult Bereavement Services are available to anyone who lives in Highland over the age of 18, who has been bereaved by the death of a family member or friend.

This form can be used for self-referral or by professionals referring a patient or client.

Person being referred

Date of birth

Address

Telephone

Gender MaleFemale

Relationship to person who has died

GP name, phone number and address

Name of person who died

Date of death

Place of death

Cause of Death

Was the person known to other Highland Hospice services? YesNo

If 'Yes', please specify below

Please explain why you are referring to the bereavement service

Has the person being referred previously undergone or are they currently receiving any bereavement counselling support? YesNo

If 'Yes', what service and when?

Name of person making referral

Only complete this section if you are referring somebody other than yourself

Position

Phone

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Registered Office: Highland Hospice, Ness House, 1 Bishops Road, Inverness IV3 5SB.
Telephone: 01463 243132. Email: generalenquiries@highlandhospice.org.uk
Highland Hospice is a registered Scottish charity, no. SC011227 and a company limited by guarantee, no. SC093464. Cookie Policy
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