Lamplight API response

Family name

Address 1

Address 2

Address 3

Address 4

Address 5

Postcode

Email address

Mobile phone

Phone number

We would like to contact the family about our services from time to time. They can opt out whenever they like, and we won't share their contact details with any other organisations. Is the family happy for us to contact them

By post

By email

By mobile

By text message

Other information

FAMILY DETAILS

Full name of parent/carer *

Relationship to child/children *

Does this adult have a disability or any additional needs?

If yes, please provide relevant details

Details of alternative parent/carer/ Next of kin

Please give details of a second contact for the children being referred

Full name of alternative parent/carer

Relationship to child/children

Email address

Telephone number (home)

Telephone number (mobile)

Details of child/children

Please complete for every child in the household if known

How many children are in the household?

Child 1

Full name *

Date of birth *

Gender *

Ethnicity

Does this child have a disability or any additional needs?

If yes, please provide relevant details below

School/nursery attended, if known

Child 2

Full name

Date of birth

Gender

Ethnicity

Does this child have a disability or any additional needs?

If yes, please provide relevant details below

School/nursery attended, if known

Child 3

Full name

Date of birth

Gender

Ethnicity

Does this child have a disability or any additional needs?

If yes, please provide relevant details below

School/nursery attended, if known

If you have more children to add, please give details below

Referral Background Information

Name of person with illness

Details of Illness

Current prognosis

Has a SR1 medical report form been completed?

Relationship of person with illness to child

Relationship of person with illness to the parent/carer *

Equality and Diversity

As a charity, we collect data on the questions below to monitor our equity and diversity

and to provide this information to grant providers who may be seeking to help certain disadvantaged groups within our society

Ethnicity of parent/carer identified above

Family's Religion

Is the family in receipt of state benefits?

Is the family in receipt of Pupil Premium Grant?

Have you previously contacted our helpline regarding this family?

Referrer Details: Professional Referral for Pre-Bereavement

Your Name

Professional Role

Contact telephone number

Contact email address

Please indicate if you would like to consent to receiving our Professional's Newsletter

Consent

Please indicate that you have received consent from the family to make this referral on their behalf and that they are happy to be contacted by a Jigsaw South East Support Worker?*

Please indicate that the family have consented to their contact information being recorded and stored on our database? *

Name of parent/carer who gave consent *

Professional Referral for Pre-Bereavement support

Other information

FAMILY DETAILS

Details of alternative parent/carer/ Next of kin

Details of child/children

Referral Background Information

Equality and Diversity

Referrer Details: Professional Referral for Pre-Bereavement

Consent