Cavendish Cancer Care

Please use the form below to refer yourself for the support of Cavendish Cancer Care or if you prefer please ring 0114 2784600 between 9 – 5 Monday to Friday. Please fill out as much of the form as you feel able to, but don’t worry if you don’t know answers to some questions. All information is treated in strict confidence.

Please note at the current time we are unable to offer face to face support but have adapted our model of care to telephone assessment and continue to develop a range of telephone and video link support everyday.

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

Online referral

A little more about you

When is a good time to call you?

Join our newsletter