Cancer Support Services Referral Form

Please fill in as much of the form that you feel comfortable with:

    1. Personal Information


    MaleFemaleOtherPrefer not to say

    PhoneEmailText

    2. Medical Information


    ChemotherapyRadiotherapySurgeryPalliativeOther

    3. Support Requested

    Options include: Emotional/psychological support, medical acupuncture, complementary therapies (e.g., reiki, massage, reflexology), mindfulness sessions, signposting to other services, financial advice, information, support groups, family/carer support.

    4. Additional Information

    Privacy Policy

    Cherry Lodge Cancer Care complies with GDPR, respects stakeholder privacy, does not share data without consent, uses data only as necessary, ensures data accuracy, retains data only as needed, secures data, and reviews this policy every two years.