We are Here To Help

Further Support

If you are looking for further guidance on how to talk to your children about an incurable diagnosis, please complete the form below. It will allow us to better guide and support you. Once submitted we will be in touch within two working days. Thank you.

Complete Form

Complete The Form Below
First Name*
Last Name*
Date of Birth*
Email*
Phone*
Address
Street Address City County / State / Region Post Code Country
Contact Preferences
Preferred Method*
Would you prefer us to email or call you?
Phone Time Preference
Are you happy for us to leave a voicemail if we can’t reach you?
About Your Children
Number of Children
Child 1 Age*
Child 2 Age*
Child 3 Age*
Child 4 Age*
Child 5 Age*
Child 6 Age*
Your GP Details
We record your GP information to support us to work safely and responsibly with you. If we should become concerned about your well-being at any time, or the well-being of other family members, we may inform your GP so that they can also be involved in your care. We will always aim to discuss this with you, but such contact cannot be guaranteed, please see our Privacy Policy for more information
Your GP Practice*
Your GP Phone Number*
Emergency Contact
We prioritise your welfare at all times and ask you to provide us with an additional emergency contact to be used in conjunction with or as an alternative to your GP. Please see our Privacy Policy for more information.
Contact Name*
Contact Number*
Relationship to Contact*
Personal Data
We would like to process personal data in relation to your health as part of the support we provide with our Family Support Service. The details of the specific data we use and a full list of the purposes which we use your data for can be found in our privacy policy here. This includes, for example, details about your mental health that you choose to share with us so we can provide you with appropriate support or direct you towards someone who can help.
Consent
- I consent to personal data about my health being used by the Ruth Strauss Foundation as part of the Family Support Service
Other Information
We prioritise your welfare at all times and ask you to provide us with an additional emergency contact to be used in conjunction with or as an alternative to your GP. Please see our Privacy Policy for more information.
What is the diagnosis?*
Who has the diagnosis?*
- Me
- I'm a health or care professional making a referral on behalf of a patient
- Other
Please Specify*
Do you have the parents' consent to share their details with us?
- Yes
- No
Referrers Name
Referrers Phone Number
Referrers' Email Address
Is there anything about your/their condition that would prevent you/them from attending a video appointment?*
Appointments usually take place via Zoom.
Is the person with the diagnosis currently under Hospice/Hospital care?*
What is the name of the hospice/hospital?
Reason for contact/referral
We would arrange an initial conversation with you on a weekday between 10am and 8pm to discuss your needs, please let us know if you have preferred availability which we will try and match.