Third Party Referral Form for Cruse Scotland

This form allows you to refer a client directly to Cruse Scotland, on the assumption that you have their consent to do so.

If the client has not given consent for you to pass on their details to us, you could be at risk of breaking GDPR guidelines. We will only accept this referral if you can confirm that you are able to act on their behalf. Cruse Scotland does not accept responsibility for NHS staff acting out with GDPR legislation so please ensure you have the consent required.

We ask you to provide us with key contact information about the person who you are referring, it is extrememly helpful if you can supply their contact email address, as this helps us to make faster contact with them. We also need to know details about the bereavement they are presenting with. Please give us as much information as you can.

Please be assured that the information you send to us is secure. Cruse Scotland has strict Data Protection processes and will not pass this information to anyone else.

Once we receive the form, we will ensure than an information pack is sent out, preferably by email, to the client. This pack will contain support literature relevant to their bereavement and information of how they can proceed to receive services from their local team of Cruse Scotland.

REFERRERS DETAILS

Your name

First name incl. title Last Name

Occupation/Role

Which is your professional relation to this client?

Is this

What is your work contact number

Area CodePhone Number

What is your work address

Street Address

Street Address Line 2

Town or City

Post Code

What is your work email address

example@example.com

Please tell us the full name of the person your are referring

First NameLast Name

Please give us their date of birth

Date

Gender

Other

What is the client's ethnicity?

What is the clients ethnic group? (Ex: Asian-Indian, White-Scottish, Mixed-White & Black African)

What is the clients Nationality? If other please specify

Their address

Street Address

Street Address Line 2

Town or City

Post Code

Please give an email address and/or a phone number - or both if possible. If you have an email address we will send the information pack via email. If the client does not have an email address we will send them an information pack by post-this will take longer to receive, please relay this to your client if need be.

Their Email Address

example@example.com

Their phone number

Does client give us consent to leave them voicemails and say it's Cruse Scotland if need be?

Who has died?

How did the person die - what was the cause of death (Please confirm with client if you are unaware)?

When did this person die? Please, as a minimum, give us the month and year they died (if logging more than 1 death please give further details under additional information)

Date

Did the person who died have any contact with acute services or hospital in Scotland?

If yes to above, which hospital did they attend?

Any other information you wish to share at this time, including other significant deaths, please give dates and cause of death if there are any (if none please type none) also if there are any additional suport needs for example, do they speak english or need an interpreter, have they learning difficulties etc.

As we tailor our information to each client, we ask if they have children under the age of 18 living with them? If so, please list their years of birth below.

It would be helpful to know what support they have at present.

Please tell us the full name of their GP surgery or health centre.

Please relay to your client that after their referral is processed, they will receive an information pack by post or email. It is then up to the client to contact their local team directly after receiving their information pack (number and email provided within the information pack). They can also contact Cruse Scotland for emotional support on our free, confidential helpline on 0808 802 6161.

Finally, we need you to confirm that you have this person’s permission for Cruse Scotland to enter their details on their confidential database and that you understand we will now make direct contact with them to follow up on this referral.

3rd Party Referral Form