Thank you for making a referral to 2wish. Please fill in as much information as follows. If you would like to speak to a member of the support team, please call us on 01443 853125.
Your name
Your email
Your phone number
Your job title
Date of referral
Name of deceased child/young person
Date of birth of deceased child/young person
Date of death of deceased child/young person
Age at time of death of deceased child/young person
Any information available
Known details regarding the cause and circumstances of death(Please consider where young person died, how young person died, when young person died, what happened)
Name of bereaved person(s) to refer
Contact number(s) of bereaved person to refer
Address(es) of bereaved person(If known)
Family details(Please consider any siblings, are parents together, any other individuals to consider)
Memory box given? —Please choose an option—Yes, 2Wish memory box givenYes, a different memory box has been givenNo, a memory box has not been given
Has verbal consent for referral been given by bereaved individuals being referred? —Please choose an option—YesNo
Has the bereaved person been informed about the PRUDiC/CDOP?
Name of police officer supporting family?
Contact details of police officer supporting family?
Are you aware of any safeguarding issues that can affect us when we visit families in their homes? YesNo If yes, please provide details:
Domestic violence: YesNo If yes, please provide details:
Mental health services: YesNo If yes, please provide details:
Drug and alcohol services: YesNo If yes, please provide details:
History of criminal offences: YesNo If yes, please provide details:
Ongoing support from other agencies: YesNo If yes, please provide details:
Please add any background information you think would be useful to us.For example, additional learning needs, physical/sensory, preferred language
