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 IDReferral Form TypeTo offer you support, we just need to ask you a few questions.Tell us your name*I identify as...MaleFemalePrefer not to sayTell 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 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 addressHow 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 selectSomeone important to me has diedSomeone important to me is near the end of their lifeBy 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
