Self Referral

Referral Form

If self-referral**, please only tick self-referral box and move on to question 1.

Self-referral (tick and move to question 1)

Family / friend referral

Agency referral

Healthcare Professional

Name of referrer

Referrer job title / Organisation

Contact telephone number or text number

Relationship to person being referred

1. Referral Form

Details of person being referred

First Name**

Last Name**

Date of Birth**

Address **

City

County

Post Code

First contact – on receipt of this application we will normally contact the person who has been referred directly by text. If you would prefer us to write to you or email or have any specific contact requirements, please let us know here.

Going forward – we may contact the person who has been referred using video call, letter and email for purposes of delivering the service.

2. Contact**

Do you agree to be contacted by:

Video call

Letter

Text

Email address

If Yes, which type of video call:

FaceTime

Zoom

Other - please state

Other type of contact:

3. Communication**

How do the client communicate? - talking, British Sign Language...

BSL

SSE

Speech/lip-reading

4. Type of support needed

What kind of support does the client need?

Tick all that apply

Advocacy

Peer Support

one to one support

Other

Other: please state

5. Cancer Diagnosis**

Do you have a cancer diagnosis, or are affected by someone else’s cancer diagnosis? If you do not have a cancer diagnosis yourself, please move onto next question

Cancer Diagnosis

Family Member/Friend

Main Carer

Please give more information about the cancer diagnosis/the cancer of the person being referred: of cancer; how long since diagnosis; current treatment or cancer stage (e.g. in remission, end of life, living with cancer no current treatment)

NHS Number:

Hospital Cancer Nurse Specialist or Community Nurse (Name & Team)

GP Name and Surgery

6. Ethnicity **

The questions below are for the purposes of data monitoring and should be completed about the person being referred. There is no need to complete the questions but it would help us if they were able to so we can ensure we are reaching all sections of our community.

Please state (any other ethnic group):

Mixed / Multiple Ethnic Groups

White and Black Caribbean

White and Black African

White and Asian

Any other mixed/multiple ethnic background

Please state (any other ethnic group):

Black / African / Caribbean

Caribbean

African

Any other Black/African/Caribbean background

Please describe:

Please state (any other Ethnic Group):

Any other Ethnic Group

Arab

Any other ethnic group

Prefer not to say

Please state (Any other Ethnic Group):

7. How would you describe your gender identity?**

Self describe your gender identity

8. How would you describe your sexuality?**

Self describe your sexuality

9. Emergency Contact details

Name

Relationship to client

Phone/Mobile

10. How did you learn of this service**

11. Declaration**

I give my consent to be contacted and for the above information to be held by Self Help (SHUK) for the Macmillan Deaf Cancer Support Project (DCSP). If you do not consent to be contacted, we will not be able to continue with your application. In accordance with GDPR, we will store these details securely, only use them for the MDCSP and will retain them for up to 7 years after your referral to us. If you no longer wish to be with us and would like your information to be deleted, please contact [email protected]

A persons NHS number may be used for purposes of sharing information with their GP/ cancer nurse or other health professional involved in their care and for purposes of viewing a previous EHNA or accessing patient records on behalf of the patient. Express permission from the patient will be obtained before using the NHS number for any of these purposes and will only be if relevant to the delivery of support from the Macmillan Deaf Cancer Support Project.

12. SORD (Social Research with Deaf People)**

Some of this information (marked with **) will be shared with Social Research with Deaf People (SORD) who are evaluating this project, but only if you have consented to take part in the evaluation study.

SORD would like to send you some information about the evaluation study so that you can decide if you want to take part.

This information is in BSL (and English) - http://https//www.deafcancersupport.org.uk/evaluation

Yes

If you tick Yes it means that we will pass on your email/contact details to SORD. we will NOT pass on any other information about you.

13. Support

If you are making a referral for a family member or friend who has cancer and this is also affecting you, you can also ask for support from us at the Macmillan Deaf Cancer Support Project.

We understand that it can be difficult for those close to someone with cancer and that you may need support in your own right. This may be someone to talk to, access to information or even some practical support if you are caring for someone.

If this is the case and you would like us to contact you also, please tick the following box and state how you would like to be contacted SMS/text or email).

I would also like some support

Please contact me by SMS/text

Please contact me by email