General Details

Are you making this referral for your family?*

Yes
No

Has a referral been made to any further bereavement organisations?

Yes
No

Please list the bereavement organisations*

Your Details

Name of Person Making The Referral*

Email*

Upload Bank Statement (3 months)

Only Required When Seeking Financial Support

Max. file size: 64 MB.

Telephone Number*

Family Details

Full Name*

Address*

Telephone*

Parent/Guardian Email*

How many dependents live in the household?*

Age of dependent(s)*

Referral Circumstances

Referral Type*

Financial Support
Respite Break
Children's Bereavement Support

Full Circumstances of Referral, Please provide full details:*

Who has died?*

Please can you help us understand more about your relationship with the person who has sadly died.

Wife/Husband
Partner/Living Together
Partner Not Living Together
Separated
Divorced
Other

Cause of death*

Date of death*

Age at the time of death*

Has the family had any other professional Involvement*

Yes
No

If 'Yes' Please provide details

Financial Support Section Break

If you have selected Financial Support Please click and answer the following questions

What support do you need:*

Mortgage
Rent Arrears
Bill Payment
Funeral Payment
Headstone Payment
Other

If 'Other' please provide details:

Respite break section

If you have selected Respite Break Please click and answer the following questions

Is the trip?*

School Trip
Day out

As There Any Special Requirements To Consider:

Yes
No

What Type of Day Out*

Theme Park
Cinema Trip
Bowling
Family Meal
Other

If 'Other' please provide details:

CBS section

If you have selected Children's Bereavement Support Please click and answer the following questions

Children Attending

Please make every effort to gather information that will assist in processing this referral.

Number of children to attend*

Name, age and gender of child attending*

Did the child or young person above attend the funeral?*

Yes
No
Attended the Wake only

Does the child or young person above understand the cause of death?*

Yes
No

Name, age and gender of child attending

Leave blank if not required.

Did the child or young person above attend the funeral?

Yes
No
Attended the Wake only

Does the child or young person above understand the cause of death?

Yes
No

Name, age and gender of child attending

Leave blank if not required.

Did the child or young person above attend the funeral?

Yes
No
Attended the Wake only

Does the child or young above person understand the cause of death?

Yes
No

GDPR*

By completing this form you agree to OUAS keeping this information stored on a secure electronic case recording system in accordance with GDPR. If you want to find more about how we use people’s information, you can access our privacy policy on our website. (here).

Make a Donation

Make a Self Referral

General Details

Your Details

Family Details

Referral Circumstances

Financial Support Section Break

If you have selected Financial Support Please click and answer the following questions

Respite break section

If you have selected Respite Break Please click and answer the following questions

CBS section

If you have selected Children's Bereavement Support Please click and answer the following questions

Children Attending