Bereaved referral form - Very Special Kids

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General news

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Donate referrals

Bereaved referral form

"*" indicates required fields

Step 1 of 5

20%

Referral details

Referral Date*

DD slash MM slash YYYY

Referrer's Name*

Referrer's first name

Referrer's last name

Relationship to child*

Relationship to child*

Organisation*

Role/Title

Phone number*

Email address*

Parent/guardian have been made aware that Very Special Kids is a paediatric palliative care service and give consent to this referral*

Yes

No

Parent/Guardian have given verbal consent for Very Special Kids to access medical information, to guide eligibility to Very Special Kids*

Yes

No

Reason for referrral*

Bereavement referral

Details

Has the child been registered with Very Special Kids previously?*

Yes

No

Unknown

Child Details

Child's name*

Child's first name

Child's last name

Date of birth*

Day

Month

Year

Sex at birth*

Male

Female

Indeterminate

Other/Prefer not to say

Gender identity*

Man, or boy, or male

Woman, or girl, or female

Non-binary

Transgender male (female to male)

Transgender female (male to female)

Prefer not to answer

Unknown/other

Preferred language*

Other languages spoken at home*

Please list all if different for both parents/carers.

Interpreter required*

Yes

No

Aboriginal or Torres Strait Islander*

Country of birth*

Child/family ethnicity

Culturally and linguistically diverse family*

Culturally and linguistically diverse (CALD) describes communities with diverse languages, ethnic backgrounds, nationalities, traditions, societal structures and religions. This may refer to people born overseas in non-English speaking countries, or people who identify with another culture or country.

Yes

No

Unsure

Child's address*

Street Address

Address Line 2

City

State / Province / Region

Postcode

Country

Child's condition*

Date of death*

DD slash MM slash YYYY

Place of death*

Family Details

Parent/Guardian 1 name*

This should be the primary or number one contact for the child.

First

Last

Relationship to child (1)*

Relationship to child (1)*

Provide more information e.g. aunt, uncle

Parent 1 address*

Same as child's address

Street Address

Address Line 2

City

State

Postcode

Country

Phone number*

Email address*

Parent/Guardian 2 name

First

Last

Relationship to child (2)*

Relationship to child (2)*

Provide more information e.g. aunt, uncle

Parent 2 address

Same as child's address

Street Address

Address Line 2

City

State

Postcode

Country

Parent 2 Phone number

Parent 2 Email address

Child and home environment

Who do the siblings reside with?*

Are there any legal/custodial issues*

Yes

No

Please provide details

Are there any risk factors we need to be aware of i.e. DV, substance abuse, protective issues etc.*

Yes

No

Please provide details

Siblings

Sibling 1 Name

First

Last

Sibling 1 Gender

Male

Female

Other

Sibling 1 Date of birth

Day

Month

Year

Sibling 2 Name

First

Last

Sibling 2 Gender

Male

Female

Other

Sibling 2 Date of birth

Day

Month

Year

Sibling 3 Name

First

Last

Sibling 3 Gender

Male

Female

Other

Sibling 3 Date of birth

Day

Month

Year

Sibling 4 Name

First

Last

Sibling 4 Gender

Male

Female

Other

Sibling 4 Date of birth

Day

Month

Year

Sibling 5 Name

First

Last

Sibling 5 Gender

Male

Female

Other

Sibling 5 Date of birth

Day

Month

Year

Are any of these children within the same family also diagnosed with a life-limiting condition that may be eligible for Very Special Kids?

Yes

No

Please provide details

Psychosocial and other information*

i.e. family dynamics, support needs, mental health needs, behavioural support, child's care needs

Support services involved

Organisation 1

Contact name

Type of support

Phone

Email

Address

Street Address

Address Line 2

City

State

Postcode

Country

Organisation 2

Contact name

Type of support

Phone

Email

Address

Street Address

Address Line 2

City

State

Postcode

Country

Counselling & emotional support

Peer & networking activities

How you can help

Events & challenges

News & resources

Contact us

Free call: 1800 888 875

Email: mail@vsk.org.au

ABN: 86 109 832 091

https://www.facebook.com/VerySpecialKids/

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https://twitter.com/auvsk

https://www.youtube.com/channel/UCZDNbHrgwNeTOUN8TDCqlMQ

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At Very Special Kids, we acknowledge the Australian Aboriginal and Torres Strait Islander peoples as the traditional custodians of the land. We acknowledge the traditional custodians of the lands across Victoria where our services are located. We also pay our respects to ancestors and Elders, past, present and future.

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