Cancer Connect NZ Referral Form

Cancer Connect NZ is a telephone support service that links people affected by cancer to a trained volunteer who has also had cancer. This service is administered by our team of specialist Cancer Information Nurses and is free and confidential.

NOTE: Do NOT use the Back Arrow on your browser, as you may lose all information already entered. If you need to review previous pages, use the Back Button at the bottom of each page.

Fill in RELEVANT INFORMATION ONLY, as not all listed options will be necessary for this CC match. However some fields are required, as marked by an asterisk (*).

* Required

I am referring someone who has been diagnosed with Cancer. I am *
This is a required question
* Required
Health Professional Name*
This is a required question
Health Professional Organisation*
This is a required question
Health Professional Email Address
Health Professional Phone Number
Has the person you are referring given consent for the Cancer Society NZ to handle this request which will involve passing their details on to the Cancer Connect NZ volunteer who will be assigned to them?*
This is a required question
* Required
Cancer Society NZ Staff Name*
Email
Phone
This is a required question
Has the person you are referring given consent for the Cancer Society NZ to handle this request which will involve passing their details on to the Cancer Connect NZ volunteer who will be assigned to them?*
This is a required question
* Required
First Name
Age
Gender
Cancer Society Division*

Please state the area/division from where the CLIENT is from

Home Phone Number
Work Phone Number
Mobile Phone Number
Email Address
Preferred Method of Contact from Peer Supporter
Best Time to be called by Peer Supporter

Please specify days and times

Ethnicity
If you selected Other for your Ethnicity type please type in your Ethnicity here.
Language - Is English your first or second language?
Languages spoken other than English
Communication Difficulties?
What other Communication Difficulties do you have
* Required
Current Diagnosis*
This is a required question
If your current cancer diagnosis does not appear in the list above please state below:
Where breast cancer [C50] has been chosen add any other relevant details e.g. Breast DCIS or Breast male
Additional Diagnosis

If you have more than ONE current cancer diagnosis please state below

* Required
Treatment*
This is a required question
* Required
Surgical Treatment*
This is a required question
What Other Surgical Treatments have you had?
* Required
Have you had additional Treatment?*
This is a required question
* Required
Surgical-Breast Treatment*
This is a required question
What Other Surgical Breast Treatments have you had?
* Required
Chemotherapy Treatment*
This is a required question
What Other Chemotherapy Treatments have you had?
* Required
Hormone Therapy*
This is a required question
What Other Hormone Therapy have you had?
* Required
Radiation Treatment*
This is a required question
What Other Radiation Treatments have you had?
* Required
Immunotherapy*
This is a required question
* Required
Gene Markers*
This is a required question
Other Gene Markers
* Required
Other Cancer Treatments*
This is a required question
Other Cancer Treatment - Additional Information
Date treatment(s) commenced

If you have commenced treatment:

Are you still in treatment?
Date treatment(s) completed

If you have completed treatment:

Age at Diagnosis

Please just type in a numeric number (example: 55)

Date of Diagnosis

Side Effects

Physical
Other Physical Side Effects?
Emotional
Other Emotional Side Effects?
Financial
Other Financial Side Effects?
Relationship Status

(Optional - This helps us match you to someone with similar life situations)

Other Relationship Status
Number of Dependent Children
Sexual Orientation
Other Type of Sexual Orientation
Employment
Financial Concerns
Reason(s) for seeking Cancer Connect NZ services

What is the type of support you are looking for?

Case Outline

To be completed by Cancer Information Nurses Only

The Cancer Society NZ cannot process your request without consent. To consent click the Back button.

If you need assistance please contact Cancer Connect NZ at the Cancer Society NZ on 0800 226237

Thank you. Your Cancer Connect NZ referral has been sent. If you have given consent, you will hear from a Cancer Society NZ Cancer Information Nurse within 7 days. Or please contact Cancer Connect NZ on 0800 226237