Referral Form

Our service is free of charge and ANYONE can refer into us, whether you are a family member, Teacher, Healthcare Professional, friend, Emergency Service worker… the list goes on. All that we ask is that the parent/main caregiver are informed of the referral so it won’t be a surprise when we get in touch. We accept referrals within Staffordshire for Children and Young People, from 0 years up to 25 years, who have a loved one with a terminal illness (death is expected within 12 months) or has died within the preceding month of the referral.