Referral Form – The Never Alone Project

Company

This field is for validation purposes and should be left unchanged.

The Never Alone Project Support for grieving children and their families/carers

Referral Details

If you need to add multiple children to this referral, please make a note of your reference number in your confirmation email and then come back and fill in this form for each subsequent child.

What type of referral is this?(Required)

New Child or Young Person Referral

Additional Child Referral

Adult Referral

Where did you hear about us?(Required)

What is your reference number?

This can be found in the confirmation email of your original referral

Referrer Details

Are you a(Required)

Parent / Carer on behalf of child

Professional on behalf of child

Adult / Young Person

Name(Required)

First Last

Organisation(Required)

Job Title(Required)

Address(Required)

Street Address Address Line 2 City Postcode Country

Email(Required)

Phone(Required)

Parent / Carer Details

Name(Required)

First Last

Email(Required)

Address if different from child

Street Address Address Line 2 City Postcode Country

Relationship to the child(Required)

Phone(Required)

Was consent given for information to be shared?(Required)

Yes

Yes, with limitations

Child Details

Child Name(Required)

First Last

DOB(Required)

Age at time of referral(Required)

Contact Address(Required)

Street Address Address Line 2 City Postcode Country

School(Required)

Year(Required)

Does the family qualify for/receive pupil premium or free school meals?

Yes

Ethnicity(Required)

Religion(Required)

Adult Details

Name(Required)

First Last

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Bereavement/ Pre- Bereavement Details:

Name(Required)

First Last

Age(Required)

Cause of illness / death(Required)

Relationship to person(Required)

Further Information

Please tell us why this person needs support(Required)

Are there any cultural/ religious or spiritual needs we should be aware of?(Required)

Yes

Please provide further information about cultural/ religious or spiritual needs

Are there any communication or disability needs, or any identified risks or concerns?(Required)

Yes

Please provide further information about communication or disbility needs, or any identified risks or concerns

Is the family receiving any other support currently?(Required)

Yes

Please provide further information about the family receiving any other support currently

Please provide us with any other information that might be relevant, such as family unit overview.

Next Of Kin

Please provide us with the details of your Next of Kin(Required)

Consent

Information Sharing Agreement (Professional Referrals)

Why this is needed:
When a professional or organisation refers a child, young person, or adult to The Never Alone Project (TNAP), we may need to share assessment outcomes, risk information, or support plans with the referring agency. This ensures joined-up, safe support for the individual.

By completing this section, the referring organisation agrees to GDPR-compliant information sharing between TNAP and their organisation for the purpose of providing appropriate bereavement or pre-bereavement support.

Information Sharing Agreement

The referring professional/organisation agrees that:

•⁠ ⁠They have informed the parent/carer/individual being referred that information will be shared between TNAP and the referring organisation to support the referral.
•⁠ ⁠They have obtained consent from the parent/carer/individual (where appropriate) for this information sharing to take place.
•⁠ ⁠TNAP and the referring organisation may share relevant information (including referral details, assessment outcomes, support plans, attendance, safeguarding concerns and risk information) solely for the purpose of coordinating appropriate support.
•⁠ ⁠All information shared will be handled in accordance with GDPR and each organisation’s privacy policies.
•⁠ ⁠Information will not be shared with any other third party unless required for safeguarding or by law, or with further explicit consent.

Consent (Professional Referrer to Complete)(Required)

I confirm that I have obtained consent from the parent/carer/individual for information to be shared between TNAP and our organisation for the purposes of assessment, support delivery, and safeguarding.

I agree that our organisation and TNAP may share relevant information as described above to ensure appropriate support.

Signature(Required)

Date(Required)

CAPTCHA