Get Support You are manually adding a new record. Please complete the information below. Text messages and email notifications will not be sent. When you have submitted the form, you will be redirected back to the e-office where you can complete the full (background) information. Unique IDHiddenReferral Form Type To offer you support, we just need to ask you a few questions.Tell us your name* I identify as... Male Female Prefer not to say Tell us a bit more about youWhich part of Wakefield District do you live in?-- Select One --AckworthCastlefordCrigglestoneCroftonFeatherstoneFitzwilliamHavercroftHemsworthHorburyKettlethorpeKinsleyKnottingleyNethertonNormantonOssettOutwoodPontefractRhyhillSandalSharlstonSouth ElmsallSouth HiendleySouth KirkbyStanleyUptonWakefield Centrex Other (not on this list)If your area is not on the above list, please specify: How old are you?- Please select -Under 8Under 14141516171819202122232425If you're under 14 you’ll need consent from a parent/carer to share your details with usYou are under 14. How old are you?*Name of your parent or carer* Your parent/carer's relationship to you* Your parent/carer's mobile number*Your parent/carer's email address How can we get in touch with you?Your mobile numberYour email address Which do you prefer we contact you on - email or mobile?My email addressMy mobile numberEither one is fineThe above details are my parents/carers Tick this box if the above details (telephone or email) are your parents or carers Please provide the name and telephone number of someone who can be contacted in an emergency* Lastly, why do you need support?Please select Someone important to me has died Someone has died by suicide Someone important to me is near the end of their life Who has died?-- Please select --MumDadBrotherSisterFoster CarerGrandmaGrandadAuntUncleFriendOtherPlease specify What was the cause of death?-- Please select --Terminal illnessSuicideRoad traffic accidentDrugs and alcoholOtherBy submitting this form, I confirm I have read and agree to Star Bereavement's Data and Privacy PolicyConsent* I Confirm I Have Read and Agree to Star Bereavement's Data and Privacy Policy CAPTCHA
