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 from 32 weeks up to 6 months old (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.
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.
Preferred contact method*

EmailPhoneEither
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*

In utero (stillbirth/compassionate induction)Newborn (0–28 days)Infant (1–6 months)
Is the baby still at the hospital/hospice or funeral home?*

YesNo
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?*

YesNo
(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.
- You understand that Forever Held provides memory castings for babies from 32 weeks gestation up to 6 months old (including late miscarriage, stillbirth, compassionate induction, neonatal and infant loss). 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