Survivorship Program – Health Professional Referral Form Empowering adolescents and young adults beyond cancer Health Professional/Service Provider Referral Form Referrer DetailsName First Last Role / Title(Required) Oncologist Nurse Social Worker Allied Health Other Service / DeptartmentOrganisation Perth Children's Hospital You Can Centre Other PhoneEmail Young Person's DetailsName(Required) First Last Date of birth (if known)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeEligible age range: 15–25 yearsPreferred PronounsPhoneEmail AddressIs it safe to contact the young person directly? Yes No Unsure If no, please provide the parent/guardian details belowParent / Guardian Name First Last Parent / Guardian PhoneParent / Guardian Email Cancer & Treatment Journey (brief)DiagnosisCurrent Situation In treatment Recently finished treatment In follow-up care Ongoing or relapsed care Not sure Treating service (if known)Reason for referral Advocacy (including support with self-advocacy) Transition from hospital to community Navigating health systems Navigating education systems Education re-engagement or vocational planning Employment support or workplace advocacy Financial stress or practical support coordination Social isolation / peer connection challenges Support understanding survivorship care and follow-up Support for family / carers Psychosocial support (referral/coordination as required) Other referral reasonsUrgency Routine (contact within 2-4 weeks) Priority (contact within 1-2 weeks) Urgent (please contact within 48-72 hours) Urgency ReasonAdditional Context or RisksPlease include any relevant information that may assist the Advocate (e.g. safeguarding concerns, disengagement from services, cultural considerations, communication needs):ConsentConsent 1(Required) I confirm that the young person (and/or parent/guardian where appropriate) has provided informed consent for this referral and for their information to be shared with the Survivorship Program.(Required)Consent 2(Required) I confirm the young person is aware of this referral and agrees to be contacted.(Required)Name of person providing consentRelationship to young person (if applicable) Δ ShareLinkedInEmailTweet
