We accept referrals from professionals and families for children aged between 3-18 years and their parents/carers affected by the death or terminal illness that has a prognosis of a year or less for survival, of someone important to them. Please note our services are currently restricted to certain geographical areas. Please refer to the details at the bottom of this page to see if you are eligible before submitting your referral form.  

Once a referral has been received, we will telephone you as quickly as possible to arrange a face-to-face, telephone or online assessment appointment with the adult parent/carer of the child being referred.

The assessment will last approximately 1.5 to 2 hours and is an opportunity for us to assess your family's individual needs and for you to find out about the services and type of support we may be able to offer.

We endeavour to offer the most appropriate service as close to home as possible at our venues in Newark, Mansfield, Ashfield, Nottingham City, Rushcliffe and Bassetlaw. However, this is dependent on matching support available which will be discussed with you. If you live in either Lincoln City, North Kesteven or South Kesteven then you can still access support if you can travel to our Newark venue.

How to access support

As much as we would love to be there for everyone, we do have some criteria for accessing our support. To find out if you are eligible please check the criteria document  and then complete the correct online form from the list below. A downloadable sample form is also available for information purposes only.   

IMPORTANT INFORMATION: there are boxes on all forms marked with an * and forms can only be submitted if these are completed.  We do ask that you complete as much detail as possible in the online form as your referral may not be accepted or may be delayed without it.

If you have any problems completing any of these forms, please call us on 01636 551739 or send us an email.

Child referral form from a parent/carer 

Child referral form from a professional 

Adult referral form 

Thank you

Sample forms for reference only are below

Child referral form from parent carer sample form 

Child referral form from a professional sample form 

Adult referral form sample form