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Bereavement Referral 2024
Bereavement Referral
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Referral Date
*
Information about the Bereaved Individual
Name
*
First
Last
Gender
*
– Please make a selection –
Male
Female
Trans Man
Trans Woman
Non Binary
Unsure
Prefer not to say
Other
Other
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Telephone Number
*
Cell Number
Email Address
Date of Birth
Marital Status
– Please make a selection –
Married
Single
Common Law
Divorced
Widowed
Other
Other
Primary Language
Religion/Spiritual Affiliation
Relationship to the Deceased
*
– Please make a selection –
Wife
Husband
Common Law
Daughter
Son
Brother
Sister
Friend
Mother
Father
Other
Other:
Was the bereaved present at the time of death?
Yes
No
Information about the deceased individual
Name
*
First
Last
Gender
– Please make a selection –
Male
Female
Trans Man
Trans Woman
Non Binary
Unsure
Prefer not to say
Other
Other
Date of Death (if not known, please state approximate date):
*
Age (at the time of death):
Cause of Death
*
Cancer
Frailty / Dementia
Suicide
Brief Illness
Organ Failure
Heart / Stroke
Overdose
Long Illness
Neurodegenerative
MAiD
Sudden / Unexpected
Other
Other
Where Death occurred
– Please make a selection –
Home
Hospital
Hospice Residence
Long Term Care
Retirement Home
Other
Other
Reason for Referral
*
Additional Information
Self-referral
Yes
No
Referral submitted by:
*
First
Last
Profession/Designation
Referring Organization
Telephone Number
*
Email Address
Submit
