Cavendish Cancer Care

Please provide as many details as possible

Name of parent /guardian completing referral*

Relationship to child*

Email*

Contact number of person making the referral*

Name of Child/Young Person*

Date of Birth*

Address where the child resides*

Is the young person fostered/adopted/looked after by someone other than the biological parents? If yes, please provide details.*

Any agencies currently providing support or previously involved with the family e.g. Social Care, MAST, CAMHS, private therapy. Is the Young Person on any waiting lists?*

Name & address of GP. ( We are only able to support people registered with a local GP, we will only contact your GP if we feel you are risk to yourself or others)*

Name & address of school*

Is the enquiry in relation to a cancer diagnosis or cancer related bereavement – please provide details.*

Diagnosis/Type of Cancer*

Outline of concerns and reason for requesting support.*

Has the child been supported by Cavendish before ? YesNo

Equality, Diversity and Inclusion Monitoring

All the following information will be kept anonymously and confidentially and used only for monitoring purposes to promote inclusivity.

Gender of Child/Young Person*

3. Is the gender the child/young person identifies with the same as your gender registered at birth?*

Ethnicity

Ethnicity - Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong

Asian or Asian British

Any other Asian background, please write in:

Black, African, Caribbean or Black British

Any other Black, African or Caribbean background, please write in:

Mixed or Multiple ethnic groups

Any other Mixed or Multiple ethnic background, please write in:

White

Any other White background, please write in:

Disability/Health Conditions and Caring

Do you consider your child/young person to have a disability or health condition?*

Other please detail

Does your child/young person have caring responsibilities? (e.g., for children, elderly relatives, or others)*

When is a good time to contact you

We are avaialble Wed-Fri 9.30 - 5.30 please tell us when is a good time to try and get back to you* Morning LunchtimeAfternoon

Or let us know a specific time/day

CYPS Referral Form

Please provide as many details as possible

Equality, Diversity and Inclusion Monitoring

Ethnicity

Disability/Health Conditions and Caring

When is a good time to contact you

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