Self Referral

Please fill in the form as much as you can, do the best you can. When we receive the form, we will be in touch.
Referral Form

Referral Form

1. Referral Form

Details of person being referred

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

2. Contact**

3. Communication**

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

4. Type of support needed

What kind of support does the client need?

5. Cancer Diagnosis**

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.

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

8. How would you describe your sexuality?**

9. Next of Kin & Emergency Contact details

10. How did you learn of this service**

11. Declaration**

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//

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).

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