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Referring someone to Canteen

male with tattoo - image for referring someone to canteen

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Referring someone to Canteen

Referring someone

Youth Cancer Service

Connect yourself or someone you know or work with to specialist support from Canteen

We need a few details so that we can provide you with the best possible support.

Get Support

By providing us with this information, we can connect you with the support services that best meet your needs.

Once you submit the form, someone from the Cancer Hub team will be in touch within 48 hours to discuss support options.

Cancer Hub is a collaboration between Canteen, Camp Quality and Redkite to help families impacted by cancer more easily access the different practical and emotional support services they need.

Please note that this form is only if you are ready to refer someone seeking support. If you have any questions about the services that Canteen and Cancer Hub provide, please contact us instead of filling this form out.

Your Details

First Name

Last Name

Email

Phone Number

Are you a:

Person seeking supportProfessionalFamily member/friend

Is the person you are seeking support for under 16?

YesNo

Is the person you are seeking support for under 16?

YesNo

Are you under 16?

YesNo

Organisation

Organisation Location

Role

Your relationship to the person seeking support

DOB

Country

State

Suburb

Postcode

Do you identify as Aboriginal or Torres Strait Islander?

Do you need a language interpreter?

Which language do you need an interpreter for?

Has the person you are seeking support for given their consent to this referral?

YesNo

Details of person seeking support

First Name

Last Name

DOB

Email

Phone Number

Country

State

Suburb

Postcode

Does the person seeking support identify as Aboriginal or Torres Strait Islander?

Does the person seeking support require a language interpreter?

Which language do they need an interpreter for?

Who should we contact regarding support options?

The person seeking support

Me
Someone else

Who should we contact regarding support options?

Me
Someone else

Who should we contact regarding support options?

Me
My parent/guardian

Other Contact Details

Please provide the details of the other person to be contacted about the support that Cancer Hub offers.

First Name

Last Name

Relationship to the person seeking support

Email

Phone Number

Parent/Guardian Details

For a young person under 16, in order to process this referral please provide the contact details of their parent/guardian. They will be contacted regarding support options.

First Name

Last Name

Relationship to the person seeking support

Email

Phone Number

Parent/Guardian Details

Please provide the details of your parent/guardian if you would like them to be contacted about your support.

First Name

Last Name

Relationship to the person seeking support

Email

Phone Number

Is the person seeking support a:

Young personParent or carerOther relationship to child/young person

Are you a:

Young personParent or carerOther relationship to child/young person

Please select the option that best describes the relationship to the child/young person

AuntUncleGrandparentExtended family memberFriendOther

Please specify

Please select the option that best describes the cancer experience for the person seeking support

I have cancer I survived cancer My sibling has cancer My sibling survived cancerMy sibling died from cancerMy parent/carer has cancerMy parent/carer survived cancerMy parent/carer died from cancerOther

Please specify

Please select the option that best describes the cancer experience for the person seeking support

I have cancer I survived cancer My child has cancer My child survived cancer My child died from cancer My partner/spouse has cancer My partner/spouse survived cancer My partner/spouse died from cancerOther

Please specify

Other information about reasons for seeking support:

Please enter any additional information about the cancer experience, best times to contact etc.

How did you hear about Canteen?

If other, please enter how you heard about Canteen

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Acknowledgement of Country

Canteen acknowledges Aboriginal and Torres Strait Islander peoples as Australia’s First Peoples and sovereign Custodians of this land. We pay our respects to Elders past, present and emerging. We are committed to providing inclusive and appropriate support for First Nations young people, their kin and community impacted by cancer. First Nations peoples are respectfully advised this website may contain images, names or stories of people who have passed away. Read our Reconciliation Action Plan here.
Ngalaya (Dharawal for ally or friend in battle), is an artwork commissioned by Canteen created by Kamilaroi and Jerrinja woman and artist Jasmine Sarin.

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Diversity and Inclusion

We are guided by our values and commitments to ensure that everyone at Canteen feels respected, included and safe. We welcome the LGBTQI+ community and people from all cultures, backgrounds and abilities.

75 King St, Newtown NSW 2042 Australia

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