Children & young persons referral

Referral criteria

We accept referral forms from parents/carers, professionals, and self-referrals.

To ensure our bereavement support is in the best interests of children and young people, we have some referral criteria. We will not be able provide one-to-one support in the following circumstances:
• If the child is under the age of five. However, we will work with parents/carers to support this age group.
• If the child or young person does not wish to explore their grief.
• When there are multiple issues and grief is not the main concern.
• If the child or young person has not been told how the person has died, using appropriate language. However, we can help parents/carers with this.

If you have any questions regarding the criteria, we are happy to chat anything through with the referrer.

Please complete all questions in the form. Incomplete forms may need to be returned so that we have a full understanding of the child or young person's circumstances.

Child/young person details

First name*

Last name*

Date of birth

School attended

Email address (if applicable)

Telephone number (if applicable)

Parent/carer information

First name

Last name

Relationship to the child/young person

Mobile phone

Landline phone

Street address 1

Street address 2

Is it ok for us to leave you a voicemail message?

Yes

Is it ok for us to text you?

Yes

What is the best time for us to contact you?

Are you looking for support for any other children or young people?

Yes

Please complete a separate referral form for each individual.

If the referral is from a third party

First name

Last name

Email address

Contact number

Street address 1

Street address 2

Has the parent/carer given you their consent for you to contact us?

Yes

Equal opportunity questions

Gender of the child/young person.

Male

Female

Other

Prefer not to say

Does the child/young person have a disability?

Yes

Please provide details of the disability

Medical support/conditions

Does the child or young person have any medical conditions (physical or mental) that we should be aware of?

Yes

Please provide details

Is there, or are you waiting for, any support for any medical conditions for the child or young person (e.g. CAMHS, counselling services)?

Yes

Please provide details

Is there a behaviour management plan in place for the child or young person?

Yes

Please provide details

Please describe the child/young person's support network (including professional services)

If you are referring a child or young person who has not experienced a parental or sibling bereavement, please describe why you feel bereavement support is needed.

If there are any other significant losses, events, or risks: (e.g. recently moved home, changes school, self-harm, talk of suicidal thoughts or feelings), please provide details.

If there is any other relevant information you think may be helpful, please provide details.

Consent to hold your information

We need to record some information about you to allow us to arrange support with a suitable support worker and to ask for feedback when your support has ended.

Your information won't be passed on to any third parties and won't be used for marketing purposes. Do you consent for us to hold this information? *

I accept

Consent to provide bereavement support

Please tick the appropriate consent statement below: *

I consent to the named child or young person receiving bereavement support from Cruse Bereavement Support Isle of Man, and confirm that I have discussed this with him/her.

I have parental/carer responsibility

I am referring on behalf of an organisation or school and have parental/carer consent

I am a child or young person referring myself

Contact us

Referral criteria

Child/young person details

Parent/carer information

If the referral is from a third party

Equal opportunity questions

Medical support/conditions

Bereavement details

Consent to hold your information

Consent to provide bereavement support