Together – Support After Suicide

Your details
Name

Date of Birth

Age

Gender

Preferred pronouns

Address

Contact Telephone Number

Email Address

Preferred contact method

About your bereavement
Who have you lost? Please tell us their relationship to you (for example, partner, parent, child, sibling, friend or colleague):

When did the death occur

Was the death a suspected death by suicide? YesNoUnsure / awaiting further information

Please tell us anything else you feel it would be helpful for us to know about what has happened.

How can we support you?
You don't need to know exactly what support you need. Please tick anything you feel may be helpful at the moment:
Someone to talk to / emotional supportOne-to-one bereavement supportSupport for my familySupport for a child or young personPractical information and guidanceSupport around the coroner or inquest processSupport around significant dates or anniversariesGroup or peer supportHelp accessing other services or supportSupport for a workplace or communityI'm not sure – I would like to talk to someone about what might helpOther – please tell us:

How are things for you at the moment?
We know that grief following a suspected death by suicide can affect people in many different ways. Is there anything you would like us to know about how you are coping or how the bereavement is affecting you at the moment?

Is there anything making things particularly difficult for you right now?

Current support
Are you currently receiving support from any other services, organisations or professionals?
YesNo

If yes, please provide any details you are comfortable sharing, including the name of the service or worker if known:

Your safety and wellbeing
We ask everyone these questions so that we can make sure the support we offer is appropriate.
Are you currently having thoughts of suicide or of ending your life?
YesNoPrefer to discuss this with a member of the team

Are you currently self-harming or having thoughts about harming yourself?
YesNoPrefer to discuss this with a member of the team

Are there any other immediate safety or safeguarding concerns that you feel we should know about?
YesNo

If yes, please provide details if you feel able:

Health and accessibility
Is there anything relating to your physical or mental health that would be helpful for us to know when supporting you?

Do you have any communication, accessibility, language or other needs that you would like us to be aware of?

Emergency contact
Is there someone you would be happy for us to contact in an emergency? YesNo

Name

Relationship to you

Telephone number

I consent to the information provided in this form being shared with appropriate professionals within Humber Wellbeing Services CIC for the purpose of assessing my referral and providing support.

I consent to being contacted by the Together team regarding my referral.