Cavendish Cancer Care

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 are only able to support people registered with a local GP, we will only contact your GP if we consider you are a risk to yourself or others)*

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 - as bad as it can be, 10 - hardly at all)*

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 Fridays in the morning and afternoon. Appointments take approximately 20 minutes. We may call you anytime in this 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. (Please tick all that are suitable)

Monday (1.30 - 4.30pm)

Tuesday (1.30 - 4.30pm)

Wednesday (1.30 - 4.30pm)

Thursday (1.30 - 4.30pm)

Friday (10.00 - 12.00am)

Friday (2.00 - 4.00pm)

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

Self Referral Form

A little more about you

When is a good time to call you?

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