HomeOur careFamily servicesSeahorse ProjectSeahorse Project referrals Seahorse Project - self-referrals Thank you for your interest in our Seahorse Project. Please complete the form below and we will be in touch as soon as possible. Please note, this service is for children and young people aged 6-18. If the young person is under the age of 13, has the main caregiver given consent on their behalf?(Required) Yes No Not relevant as over 13 Is the young person aware that the referral has been made on their behalf?(Required) Yes No Not relevant as I am the young person Your details as the referrerName(Required) Mr.MissMrs.Ms.Dr.Prof.Rev. Prefix First Last Your relationship to the young person(Required)MotherFatherGrandparentAuntUncleSiblingFamily friendProfessionalOrganisations name(Required)Your Date of Birth(Required) DD slash MM slash YYYY Your contact phone number(Required)Your email address(Required) Young person's detailsTheir name(Required) First Last NHS Number (If Known)As we move towards joined-up working with other healthcare organisations, providing us with your unique NHS number enables us to quickly and accurately find you and the people most important to you, to facilitate improved care, treatment, counselling and support.Their Date of Birth(Required) DD slash MM slash YYYY Their address(Required) Street Address Address Line 2 City ZIP / Postal Code Their GP surgery(Required)Their school/college(Required)What is their gender?(Required) Female Male Non-binary Gender fluid Prefer not to say How would you describe their ethnicity?(Required) White British Black British Mixed British Irish African Caribbean Chinese Bangladeshi or British Bangladeshi Pakistani or British Pakistani Indian or British Indian Other Asian Background Other Black Background Other Mixed Background Other White Background Prefer not to say Other What is their first language?(Required)What is their religion?(Required) Church of England Catholic Judaism Muslim Sikh Hindu None Prefer not to say Other How do they describe their sexual orientation?(Required) Homosexual / Gay / Lesbian Heterosexual / Straight Bisexual Pansexual Asexual Undecided Prefer not to say Other About the bereavementHas the young person or a family member been previously supported by the hospice?(Required) Yes No Name of deceased(Required)Details of the death(Required)Is there any additional information you feel would be helpful to share at this time?Consent(Required) By ticking this box I give consent for the personal data recorded here to be processed securely by St Wilfrid’s Hospice Our full Privacy Notice can be found at https://www.stwhospice.org/information/privacy-notice/CAPTCHA