Seahorse Project referrals - St Wilfrid's Hospice (Eastbourne)

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.

If the young person is under the age of 13, has the main caregiver given consent on their behalf?(Required)

Yes

Not relevant as over 13

Is the young person aware that the referral has been made on their behalf?(Required)

Yes

Not relevant as I am the young person

Your details as the referrer

Name(Required)

Prefix First Last

Your relationship to the young person(Required)

Organisations name(Required)

Your Date of Birth(Required)

Your contact phone number(Required)

Your email address(Required)

Young person's details

Their 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)

Their address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Their GP surgery(Required)

Their school/college(Required)

Have you or a family member been previously supported by the hospice(Required)

Yes

Details of the death(Required)

Is there any additional information you feel would be helpful to share at this time?

CAPTCHA

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