If you are 13 - 15 years old and someone you know is very ill or has died, you don't have to face it alone. You can share your story with us, and we'll help guide you to the support that is right for your needs.

Remember, if you feel you need support sooner, our On Demand Services (Help/Support Line and Live Chat) are always open to you.

If you tell us that you, or someone you know is being hurt or is a risk of any kind of abuse, harm or neglect, we are required by law to share this information with the relevant authorities such as social services or the police, and/or your parent/carer.

I am filling this out by myselfI am filling this out with support from someone I trust

Name:

Relationship to you:

Contact details of your parent or carer

Who do you live with? (e.g. parents, grandparents, adoptive parents, foster carers)

Details of your primary parent or carer

Their first name

Their last name

Their phone number

Their email address

Their relationship to you:

Details of an additional parent or carer

Their first name

Their last name

Their email address

Their phone number

Their relationship to you:

Does your parent/carer know you've reached out to Winston's Wish?

YesNo

Do you agree to us contacting your parent/guardian to discuss the best support for you?

YesNo

Are you okay with us letting them know that you've been in touch with Winston's Wish?

YesNo

We will be emailing your parent/guardian to let them know about the best support for you. Please remind them to check their junk folder as sometimes our emails find their way there.

Please tell us why you said No

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Your details

First name

Last name

Pronouns

Pronouns - other (please specify)

Date of birth

Please use DD/MM/YYYY format

Age

Mailing Street

Town/City

County

Postcode

Phone number

Email address

Ethnicity

Please specify

Which gender do you identify with

Please tell us

Do you have any religious or spiritual beliefs?

YesNo

Please tell us more

Their main language

Please specify

Are you in an educational setting?

YesNo

If yes, please share the name of your educational setting?

Which doctor's surgery are you registered with?

How did you hear about Winston's Wish?

Please specify

Have you contacted any of our on-demand services? (this could be our helpline, email or live chat)

YesNo

Please provide details about the person who has died

First name of the person who has died

Last name of the person who has died

Who was this person to you?

Other (please specify)

When did they die

Please use format DD/MM/YYYY

How old was this person when they died (don't worry if this isn't exact)?

How did they die?

Is there anything else you want to tell us about how they died?

How have you been since the person died?

Please tell us who you go to for support

Please tell us about any other significant life events

All our services are remote, are you happy to continue?

YesNo

Please also remember that you can reach out using one of our on-demand services (Live Chat, Helpline and ASK email). Young people can also access these services directly too! Someone is available to talk from Monday to Friday, 8am to 8pm. Visit our website for more details https://www.winstonswish.org/supporting-you/grief-support-young-people/

Please select how you feel about each statement below

	That sounds a lot like me	That sounds a bit like me	I can't decide if that sounds like me or not	That doesn't sound a lot like me	That doesn't sound like me at all
I can deal with the feelings I have about the important person dying
Difficult thoughts about the important person's death keep going round in my head
I am coping with life since the important person died
I try to stop myself feeling upset about the important person's death
I worry that my feelings about the important person dying will never get better
I can't let other people see how I am feeling about the important person's death
Since the important person died, I feel confused by how different life seems
I try not to think about the important person's death
Although the important person's death has been difficult for me, I am hopeful that things will get better

CAG Score

Over the last week...

Please select which best describes the following statements

	Not at all	Only occasionally	Sometimes	Often	Most or all of the time
I've felt edgy or nervous
I haven't felt like talking to anyone
I've felt able to cope when things go wrong
I've thought of hurting myself
There's been someone I felt able to ask for help
My thoughts and feelings distressed me
My problems have felt too much for me
Its been hard to go to sleep or stay asleep
I've felt unhappy
I've done all the things I wanted to

Can you tell us more about why you feel like hurting yourself

Can you tell us who you have shared your thoughts of self-harm with, if anyone?

YP-CORE score

Can you advise when would be best to call you, should we need to get in touch?

Hearing from Winston’s Wish

We would like to share ways for you to stay connected with Winston’s Wish beyond the service you will be receiving both now and in the future. This will include news of events and ways to support our work including fundraising and volunteering. The services you receive from us will in no way be impacted by your choice to support our work. You can opt out of these communications, should you wish, at any time.

Yes, I'm happy to hear from Winston's Wish by Email

Yes, I'm happy to hear from Winston's Wish by Post

Yes, I'm happy to hear from Winston's Wish by Phone

Yes, I'm happy to hear from Winston's Wish by Text Message

By submitting this referral form you are agreeing to share your information with us. If you would like to read our privacy policy please click here

I understand and agree