Bereavement Services Professional Referral Form

Details of Referring Professional or Organisation

Referral Source

Your Position Title

Your Name

Your State

Your Email Address

Your Phone Number

Has the person you are referring given their permission for this information to be shared with the Red Nose Bereavement Service and for us to contact them?

Yes

If ‘no’, they will need to contact us directly. Phone: 1300 308 307 Email: support@rednose.org.au

Baby/Child's name

Baby/Child's Date of Birth

Baby/Child's Date of Death

Baby/Child's Gender

Female

Male

Non-binary

Unknown

Aboriginal or Torres Strait Islander

Yes

Unknown

Cause of Death

Age at Death

Is the Baby/Child a twin or multiple?

Yes

Unknown

Details of the Person You Are Referring

Relationship to Baby/Child

Full Name

Email Address

Phone Number

State of residence

Is an Interpreter Required?

Yes

Does this person have any known physical / behavioural / substance use problems?

Yes (please provide details below)

Unknown

If yes to the question above, please provide details:

Are there any possible risks for counselling or/and support staff?

Yes (please provide details below)

Unknown

If yes to the question above, please provide details:

Any other relevant information?

Please note the Red Nose Bereavement Support Service is not a ‘crisis intervention’ service for people considered at risk. Our focus is on providing grief and bereavement services. Outside of business hours, you can contact our 24/7 Support Line on 1300 308 307.

Details of Second Person You Wish to Refer for this Case

Please complete this section only if there is a second person who requires a referral for counselling services for this case.

Has this person given their permission for this information to be shared with the Red Nose Bereavement Service and for us to contact them?

Yes

If ‘no’, they will need to contact us directly. Phone: 1300 308 307 Email: support@rednose.org.au

Their Relationship to Baby/Child

Second person's full name

Email Address

Phone Number

State of Residence of second person

Does this person have any known physical / behavioural / substance use problems?

Yes (please include details below)

Unknown

If yes to question above, please provide details:

Are there any possible risks for counselling and support staff?

Yes (please provide details below)

Unknown

If yes to question above, please provide details:

Do they require an Interpreter?

Yes

Unknown

Any other relevant information about this person or case

Thank you

Thank you for completing this referral form. Our team will review the information and contact the person you have referred in the next 5-7 business days.

By submitting this form, you are agreeing to our privacy policy.