Community Referral Form
Please fill out this form to refer a family or child for grief support services.
Parent / Guardian Contact
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Relationship to child(ren)
*
Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Accepts texts?
*
Yes
No
Contact Email
example@example.com
Child Information
Child Records
*
Bereavement Details
Who died? (name or nickname)
When did the death occur?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to child
Type of death
Illness
St. Francis Hospice
Accident
Suicide
Traumatic
Other
If Other, please explain
*
School Information
School(s) child(ren) attends
*
School contact
School phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Contact email
example@example.com
Consent and Services Requested
Agreement for NorthStar Staff to Contact the Family
*
Yes
No
Services Requested
*
Group Grief Support
Family Grief Support
Individual Grief Support
Camp Good Grief
Little Lights Playgroup (children ages 1-4)
Community Social Events
Observations and Notes
New behavior presenting since the death
Comments / concerns
Additional Information (per child)
Referral Authorization
Referrer Name
*
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Agency/School Name
*
Submit
Submit
Should be Empty: