LOCUS Referral Form – Encapsulate

If you are interested in joining the group, or are a healthcare professional wanting to refer someone to the group, please complete the form below. We will use this information to assess if the group is suitable for you or your referral, and to contact you regarding the next steps in the process.

Unique ID

I am a…(Required)

Loved one of someone with cancer

Healthcare professional

Referral Name(Required)

Forename Surname

Referral Date of Birth(Required)

Referral HEY Number

Referral NHS Number

Referral Email Address

Referral Contact Number(Required)

Referral Current Address

Street Address Town/City Postcode

Referral Next of Kin Name(Required)

Forename Surname

Referral Next of Kin Relationship(Required)

Referral Next of Kin Contact Number(Required)

Please provide a brief description of why you would like to attend the group.

Please state the reason that the referral would like support at this time (please include a brief outline of current concerns)

I can confirm that…(Required)

I have a loved one who is currently receiving oncology care with HUTH or has done so in the last 5 years

I do not have a cancer diagnosis myself

Consent(Required)

I agree that, to the best of my knowledge, the above information is correct. I also agree to be contacted by a member of the Cancer Psychological Service regarding this referral.

Referrer Details

Referrer Name(Required)

Forename Surname

Referrer Role(Required)

Referrer Contact Address(Required)

Street Address Town/City Postcode

Referrer Contact Number(Required)

Referrer Contact Email(Required)

On behalf of the referral, I can confirm that…(Required)

The referral has a loved one who is currently receiving oncology care with HUTH or has done so in the last 5 years

The loved one concerned is not deceased

The referral does not have a cancer diagnosis themselves

I have obtained the loved one’s consent for this referral

Comments

This field is for validation purposes and should be left unchanged.