Family Referral

We offer support to families who live within the North West Region who have been affected by a diagnosis of cancer or other life-limiting condition. Once we have received a referral, we aim to make contact within 7 days.

Self-Referral Form (Family)
Please tell us how you heard about Beechwood *

Diversity Indicators

Parent / Guardian Details

Telephone Details
Is it OK to leave you a voice message? *
How can we contact you?
Email helps the charity to reduce paper and postage costs.

Child / Young Person Details

Contact details of the child/young person if over the age of 16
Is it ok to leave a message?
Is it ok to contact you by email

Diagnosis Information

Details of other children in the family

Child 1
Child 2
Child 3
Child 4

Details of other adults in the household

School Provision
Please tick as appropriate
Referrer Details
Have the family agreed to this referral? *
Is this a family self-referral? *
Please provide details of social worker, where social care support is received

Further Child Information

Is the child adopted or in the process of adoption? *
Is the child under the care of the local authority? *
Are all those holding parental responsibility in agreement with counselling/therapy? *
(e.g. transport, school or employment pressures)?
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