Cruse Scotland Military Bereavement Form

Cruse Scotland Referral: Empowering Bereaved Military Families
This form is for self-referral into the Empowering Bereaved Military Families service.

The form asks you to tell us a little about yourself, and then a little about the person whose death you are grieving. You can also provide information on a dependent under 18 if you would like to refer them for bereavement support. Please give us as much information as you can.

Please be assured that your information is secure. Cruse Scotland has strict Data Protection processes and will not pass your information to anyone else beyond the Empowering Bereaved Military Families project.

Once we receive your form, we will send you a pack with relevant information about grief support though the Empowering Bereaved Military Families project, together with details about the next steps to accessing support

PLEASE ONLY FILL THIS FORM IN IF YOU ARE THE BEREAVED PERSON
Please tell us as accurately as you can, the date on which you first approached us

DayMonthYear
Date
How did you first contact us
Your name

First NameLast Name
Please give us your date of birth

DayMonthYear
Date
What is your Ethnicity?
What is your Ethnic Group? (Ex. White-Scottish, Asian-Pakistani, Mixed-White & Black African)
What is your Nationality? If other, please indicate

Other
Gender
Your address

Street Address

Street Address Line 2

Town or CityCounty

Post Code
How did you hear about Cruse Scotland?

Other
Please give both an email address and phone number. If you have an email address we will send the pack via email.
Email Address
example@example.com
Your phone number
Who has died
How did the person die - what was the cause of death?
When did this person die? Please, as a minimum, give us the month and year they died
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)
If necessary, are we able to leave a message on your number provided stating it's Cruse Scotland?
Do you have children under the age of 18 living with you? If so please list their years of birth below.
Are you looking to access support for any of your children? If so, please give us their details below including: First Name / Last Name / Date of Birth / Gender / Address/ Ethnicity/Nationality (if different from yours)
It would be helpful to know what support you have at present for your grief, if any.
Please tell us the full name of your GP surgery or health centre.
By confirming 'Yes' - you are providing your permission for Cruse Scotland to enter your details on our confidential database
By confirming 'Yes' - you are aware, where appropriate, we may pass your details to partner organisations within the Empowering Bereaved Military Families project if we feel their support would be helpful for you. We will let you know if we do this.
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Cruse Scotland Referral: Empowering Bereaved Military Families