Cavendish Cancer Care

That includes people with a current or previous cancer diagnosis but also family members or carers of people with cancer. We provide individually tailored support to help alleviate the emotional impact of cancer, and the physical side effects of the illness and its treatment. Support is easily accessible and is provided online, by telephone and in person. We are a registered charity, and all of our services are provided free of charge.

We are a self-referral service, so you don’t need to be referred by a healthcare professional, just fill in the short form below. We will then arrange an initial telephone appointment with one of our Cavendish Care Coordinators. This call will provide an opportunity to gather further information about your situation and tell you more about our range of services and how we can best support you.

If you are unable to complete the form online you can call us on 0114 278 4600 and leave a message with your contact details.

Full Name*

Address (inc postcode)*

Email*

Telephone Number*

Can we leave a voicemail ?* YesNo

Can we text you ?* YesNo

Date of birth*

Have you been supported by Cavendish before?* YesNo

Which of the following best describes you?* I'm a cancer patientI'm supporting a family member with cancerSomething else

If 'something else', please tell us a little more:

Name of GP/Practice ( We will only contact your GP with your consent)*

Diagnosis/type of cancer*

Date of Diagnosis

Hospital Treated at/Consultants name

A little more about you

What’s the main reason you have got in touch with us today (click box below for options)*

In relation to the concern you have identified above, please indicate to what extend this is a problem (1 - not at all, 10 - bothers me greatly)*

If you are able please complete questions below, this information is very helpful in evaluating our service and helping us to raise funds for our charity.

How would you rate your overall physical health in the past week ? (1 - as bad as it can be to 10 - as good as it can be)

How would you rate your overall emotional wellbeing in the past week ? (1 - as bad as it can be to 10 - as good as it can be)

How would you rate your relationships with friends and family in the past week ? (1 - as bad as they can be to 10 - as good as they can be)

To what extent were you able to go about your usual day-to-day activities in the past week (e.g. work, hobbies, self care)? (1 - not able to do any of your usual activities to 10 - able to do all of your usual activities)

When is a good time to call you?

Telephone calls with our Cavendish Care Coordinators take place between 1.30 – 4.30 Monday to Thursday and take approximately 20 minutes. We may call you anytime in this three hour window but please don’t worry if you can’t pick up first time we will call you back. We don’t offer specific times because we want to ensure as much time is taken as each person needs.

Monday (1.30 - 4.30pm)

Tuesday (1.30 - 4.30pm)

Wednesday (1.30 - 4.30pm)

Thursday (1.30 - 4.30pm)

If there is a better time to call you within the window please let us know and we'll try to accomodate this if possible

Within 2 working days of you filling out this form you will receive an email confirming the time of your call with the Cavendish Care Co-ordinator.

We have an e-news with news and events about Cavendish, if you would like find out more please indicate below (you can unsubscribe at anytime)* Yes please add me to the e-news service.No thanks I don't want to be added right now

We will store and use your data in line with standard GDPR regulations to ensure we provide an effective service and for evaluation and funding purposes. Further information can be viewed in our privacy policy

Online Self Referral

A little more about you

When is a good time to call you?

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