Referral Form Client / Patient DetailsClient / Patient Name(Required) First Last Client / Patient Email Address(Required) Referrer (Health Professional) DetailsReferrer Name(Required) First Last Role / Position(Required)Referrer Email Address(Required) Phone NumberSignature of health professional.(Required)Referral Document(s)Referral document(s) Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, jpeg, png, Max. file size: 120 MB, Max. files: 5. Upload any supporting referral documentation.EligibilityForever Held Foundation is a registered charity that offers support for parents and families who have experienced the death of a child through miscarriage, stillbirth, medical termination, infant death, illness or accident. Any bereaved parent who has experienced child loss from conception to age 18 is eligible for a short stay (2-4 nights) at our retreat.Whilst we will endeavour to accommodate all requests, priority will be given to those who have experienced child loss within the previous 12 months. However, Forever Held recognises that the experience of grief is ongoing, so please continue to refer a patient/client who you believe may benefit from a short stay no matter how much time has passed.Date(Required) DD slash MM slash YYYY Date of Child Loss(Required) DD slash MM slash YYYY Type of LossConfirmation(Required) I confirm that my client/patient meets the eligibility requirements outlined above for a short stay through their own experience of child loss.
