Together for Short Lives
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Butterfly Fund Referral Form

This form (below) should be completed by a professional who has been involved in delivering palliative care to a family before/at/after a child’s death.

In order for us to be confident that the family meet the Butterfly Fund’s criteria, please include details of how, and for how long you have known the family, under “How are you known to the family

Families are only able to receive one grant so please check that another service or agency has not previously referred them.

Please take extra care when completing the family email address as an error will delay payment.

Unfortunately, we do not have capacity to respond to each referral and will only contact you should further information be required.

If approved, we will approach the family for bank details in order to make the grant payment.

Butterfly Fund Family referral form