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National 24-Hour Helpline
1800 391 391
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Bereavement Support
Submit Referral
Referral Form
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Referral Form
If you wish to contact FirstLight for support please complete the referral form below
Child’s Details:
Child’s Name:
Date of Birth:
Date of Death:
Cause of Death:
Parents’ Details:
Mother’s Name:
Father’s Name:
Siblings (name and age of each)
Address:
Mobile/Landline Number:
Email:
Eircode:
Select County:
--Select County--
Carlow
Cavan
Clare
Cork
Donegal
Dublin
Galway
Kerry
Kildare
Kilkenny
Laois
Leitrim
Limerick
Longford
Louth
Mayo
Meath
Monaghan
Offaly
Roscommon
Sligo
Tipperary
Waterford
Westmeath
Wexford
Wicklow
Frontline Professional Use Only:
Person Making Referral:
Position:
Organisation/Service Provider Name:
Email:
Telephone:
Any additional Notes:
Additional Fields
Next of Kin Name
Next of Kin Phone Number
Preferred Day of the Week to Call-back:
Monday
Tuesday
Wednesday
Thrusday
Friday
Preferred Time of the Week to Call-back
Who is Seeking Support
Mother
Father
Sibling
Couples
Other
Support Sought
Call Back
Individual Therapy
Couple Therapy
Online or Face to Face
Support for Children
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National 24-Hour Helpline:
1800 391 391
Head office:
+353 (0) 1 873 2711