Contact us

Preferred method of contact (we will try to use your preferred method where possible)

Phone

Text

Any

Is it ok to leave you a voicemail?

Yes

Is it ok to send you a text?

Yes

Equal opportunities questions

Gender

Male

Female

Other

Prefer not to say

Do you consider yourself to be a disabled person?

Yes

Please let us know the details of your disability/ies

Medical support/conditions

Do you have any medical conditions that we should be aware of (including mental health)?

Yes

Please provide details

Do you have, or are you waiting for, any support services for medical conditions (e.g. counselling services)?

Yes

Please provide details

How are you feeling on a scale from 1 to 10 (where 1 is very low and 10 is very good)?

Why did you choose this number?

What was the name of the person who has died?

What was their relationship to you?

What was their cause of death?

When did they die?

If there is any other information you would like us to be aware of, please provide details.

What support do you have at the moment (e.g. GP, family, friends)?

Would you prefer face-to-face support, telephone support, or either?

Face to face

Telephone support

Either

When would you be available for sessions at our office?
(At this stage, we can't guarantee specific times for appointments)

Mornings

Afternoons

Evenings

Anytime

When would you be available for telephone sessions?
(At this stage, we can't guarantee specific times for appointments)

Mornings

Afternoons

Evenings

Anytime

How did you hear about Cruse?

If you will also be making a referral for a child or young person, please provide their name(s) below. This will help us to link family members on our database. A separate children & young person's referral form should be completed for each individual.

We need to record some information about you to allow us to arrange support with a suitable volunteer and to ask for feedback when your support has ended. Your information won't be passed on to any third parties and won't be used for marketing purposes. Do you give your consent for us to hold this information? *

I accept

Contact us

Equal opportunities questions

Medical support/conditions

Bereavement details

Type of support