HUUG Bereavement Referral

HUUG Bereavement Referral Form

For children and youth, under the age of 18, coping with the loss of a significant person in their life
Demographic Information About the Child/Youth being Referred
Referral Date*

MonthDayYear
Name*

First NameLast Name
Gender*
Address*

Address

Address Line 2

CityProvince

Postal Code
Date of Birth

MonthDayYear
Age*
Primary Language
Secondary Language
Child/Youth Relationship to the Deceased Person*
Relationship of the bereaved to the deceased person
Is the Child/Youth Informed of the Cause of Death*
Current Living Situation*

MotherFatherGrandparentSiblingOther Family MemberOther
Additional Children
If referring more than 1 child from the same family, add First Name, Last Name, Date of Birth and Gender in this section.
Reason for Referral and Additional Information
Information About the Deceased Person
Name*

First Name of the DeceasedLast Name of the Deceased
Gender*
of the Deceased
Relationship of the deceased to the Child/Youth*
Date of Death

MonthDayYear
If the date is not known, please complete the next question.
Approximate Date of Death
If the exact date of death is not entered above
Information surrounding medical history and cause of death*

CancerOrgan FailureNeurodegenerative DiseaseFrailty/DementiaHeart Attack/StrokeMAiDSudden/Unexpected deathDeath by SuicideDeath by OverdoseBrief IllnessLong Illness
Where Death Occurred
Parent/Guardian Information
Name*

First Name (Parent/Guardian)Last Name (Parent/Guardian)
Gender*
(Parent/Guardian)
Relationship of the Parent/Guardian to the Child/Youth*
Primary Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address - complete if different from above

Address

Address Line 2

CityState / Province

Postal / Zip Code
Primary Language
(Parent/Guardian)
Secondary Language
(Parent/Guardian)
Relevant family/custodial information
School Information
Is the school aware of the death?
School Name
School Location
Referral Source
Referral Submitted by*
First Name Last Name
Referring Organization
Other:
Organization name if not listed above
Referral Contact Number*
Please enter a valid phone number.
Referral Email
example@example.com
Should be Empty:

HUUG Bereavement Referral Form

Demographic Information About the Child/Youth being Referred

Information About the Deceased Person

Parent/Guardian Information

School Information

Referral Source