Leeds Suicide Bereavement Service Referral Form

To be referred to LSBS we need some details about you and your loss. The details given will be treated as private and confidential and will not be shared without your permission. We use this information to help us support you, you should expect to hear from us within 7 working days after receiving this form.

Full Name:

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* 1. Full Name:

Postcode (some of our support is only available to Leeds postcodes)

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* 2. Postcode (some of our support is only available to Leeds postcodes)

Contact number:

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* 3. Contact number:

Date of Birth and your gender

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* 4. Date of Birth and your gender

How did you hear about our service?

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* 5. How did you hear about our service?

Do you have any physical/ communication needs? (please specify)

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* 6. Do you have any physical/ communication needs? (please specify)

About the person you lost to suicide:
Name, age, gender, date of death, relationship to you.

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* 7. About the person you lost to suicide:
Name, age, gender, date of death, relationship to you.

Are there any children/young people (under 25) affected by this loss? If so please tell us their ages.

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* 8. Are there any children/young people (under 25) affected by this loss? If so please tell us their ages.

Are you accessing other support? (If so what?)

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* 9. Are you accessing other support? (If so what?)

We are based at Clarence House in Horsforth, please indicate which days you would be available for an initial meeting?

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* 10. We are based at Clarence House in Horsforth, please indicate which days you would be available for an initial meeting?

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