Refer yourself

Please note that we take referrals from 12 weeks after a death. This form is for over-18s only. We offer bereavement support to all adults in north Essex; no hospice connection is needed.

To refer yourself for support, please complete the form below. It should take around 10-15 minutes. Fields marked * are mandatory and must be completed before you can submit the form.

When you submit your referral correctly, a reference number will appear on screen. If you do not see a reference number after you submit your referral, please ensure you have completed all mandatory fields. If you experience any technical issues, please contact the bereavement team on 01206 984 274.

Please be aware that we can no longer accept referrals for bereavement support for individuals who live in mid-Essex. From 1st February 2025, the bereavement support service for those living in mid Essex will transfer to Farleigh Hospice in Chelmsford. We recommend that you refer yourself for their service via their website at www.farleighhospice.org.