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Refer yourself for bereavement support

Please note, we take referrals from 12 weeks after a death. This form is for over 18s only. We offer bereavement support to all adults in north Essex, no hospice connection is needed. To refer yourself for support please complete the form below - it should take around 10-15 minutes. Fields marked * are mandatory and must be completed before you can submit the form. When you correctly submit your referral a reference number will be given to you on screen. If you do not see a reference number once you have submitted your referral please check you have completed all of the mandatory fields. If you experience any technical issues please contact the bereavement team on 01206 984 274. Please be aware, we can no longer accept referrals for bereavement support for individuals who live in mid Essex. From 1st February 2025 the bereavement support service for those living in mid Essex will transfer to Farleigh Hospice in Chelmsford. We recommend referring yourself for their service via their website www.farleighhospice.org

Your details

If your GP surgery is not listed, please press here for more information.

Please provide a telephone number that is safe for us to use. We will use this number to contact you about your appointments and care at St Helena. Please make sure it is your own number, or the number of someone you are comfortable having access to information about your care. You can change this at any time by contacting us.
Please provide an email address that is safe for us to use. We will use this to contact you about your appointments and care at St Helena. Please make sure it is your own email address, or the email address of someone you are comfortable having access to information about your care. You can change this at any time by contacting us.
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