Referral Form - Forever Held

Referral Form - Forever Held

Forever Held provides in-person hand and foot memory castings for families who have experienced baby loss, covering all types of pregnancy loss through to six months of age (including stillbirth, compassionate induction, neonatal and infant death). This form gathers information so that Forever Held can contact the referrer to discuss suitability, timing and next steps. Families are not contacted directly unless this has been agreed in advance.
Please complete all required fields. We will contact you directly to discuss next steps and support planning.
Referrer Details
Referrer's Role
Your full name

First NameLast Name
Your role/title
Hospital/Hospice/Funeral Directors
Email address
example@example.com
Phone Number
Please enter a valid phone number.Format: 00000000000.
Date of referral

DayMonthYear
Date
Family/Parent Details

Family details are collected for context only. Forever Held will contact the referrer first and will not contact the family directly unless agreed.
Parent/Guardian name(s)
Best contact email
example@example.com
Best contact phone
Please enter a valid phone number.Format: 00000000000.
Preferred contact method
Baby Details
Baby's name/preferred name
(Enter N/A if no name)
Date of birth

DayMonthYear
Date
Gestation at birth
Date of passing

DayMonthYear
Date
Baby’s age at the time of loss
Is the baby still at the hospital/hospice or funeral home?
Location of baby
Hospital ward, hospice, funeral home or other location (if applicable)
Referral Context & Notes
Are there any time sensitivities or considerations we should be aware of?
For example: funeral date, hospital discharge timeline, cultural or religious considerations.
Any additional information
Has consent been given by the family for this referral?
(IMPORTANT: You must only submit family details if they have given consent.)
Consent & Contact Process
By submitting this form you confirm:
- The family has consented to share their information with Forever Held CIC.
- You understand how their data will be used in line with our Privacy Policy.
- Forever Held CIC will hold and process this information only to arrange casting support.
- We will contact the referrer first to discuss next steps.
Should be Empty:

Referral Form - Forever Held

Referrer Details

Family/Parent Details

Baby Details

Referral Context & Notes

Consent & Contact Process