Make a referral to Crocus Group

If you know a child who may benefit from our services, you can either print off a paper form, fill it in and send it to us, or use the online form below.

Please note that prior to them attending any Crocus Group sessions, the child / young person must be told that the person has died, and have an appropriate understanding of how they died.

Referral

Child / young person being referred

Address

Email

Telephone

Date of birth

Gender MaleFemale

School

GP name, phone number and address

Next of kin name

Relationship to child / young person

Next of kin email

Next of kin telephone

Address (if different from child / young person)

Name of person who died

Date of death

Relationship to child / young person

Information about the cause and circumstances of the death

Your name

Your relationship to the child / young person

Your email address

Does the parent or carer consent to this referral? YesNo

Does the child / young person consent to this referral? YesNo

What does the child / young person understand about the death?

Do you know of any other relevant bereavements affecting the family?

Other relevant family history

Is the child / young person experiencing any problems related to the bereavement e.g., sleep disturbances, behavioural problems etc.

'Are any other agencies or services involved with the child / young person or their family YesNo

If yes, who?

If yes, are they aware of the referral to our group? YesNo

Any other information you think may be relevant e.g. potential transport or finance problems attend sessions

Management of personal data by Highland Hospice conforms to all current legislative requirements. You can find our full Privacy Notice here.

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