If you are 16 years old or over, 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 at 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, the police and.or your GP

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

Name:

Relationship to you:

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

Page 2

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:

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/

What age group are you in?

16-1718-25

16-17 year old

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

18-25 year olds

Please select how you feel about each statement below

	Strongly Agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
I feel able to face the pain which comes with loss
For me, it is difficult to switch off thoughts about the person I have lost
I feel very aware of my inner strength when faced with grief
I believe that I must be brave in the face of loss
I feel that I will always carry the pain of grief with me
For me, it is important to keep my grief under control
Life has less meaning, for me after this loss
For me, it's best to avoid thinking about my loss
It may not always feel like it but I do believe that I will come through this experience of grief

AAG Score

Can you tell us a bit more about how you feel you are able or not able to face the pain that comes with loss?

Can you tell us why you find it difficult to switch off?

Tell us a little bit more about what gives you strength?

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 have felt tense, anxious or nervous
I have felt I have someone to turn to for support when needed
I have felt able to cope when things go wrong
Talking to people has felt too much for me
I have felt panic or terror
I have made plans to end my life
I have had difficulty getting to sleep or staying asleep
I have felt despairing or hopeless
I have felt unhappy
Unwanted images or memories have been distressing me

Can you tell us more why you have been thinking about ending your life

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

CORE-10 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