Survivorship Program - Family Member Referral Form - Child Cancer Research Foundation

PO Box 1118, West Perth WA 6872

+61 8 9363 7400

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Survivorship Program – Family Member Referral Form

Empowering adolescents and young adults beyond cancer

Family Member Referral Form

Use this form if you’re a parent, carer, or family member seeking support for a young person after cancer.

Your Details (Person completing this form)

Name(Required)

First Last

Relationship to the young person(Required)

Parent

Carer

Sibling

Partner

Other

Phone

Email(Required)

Young Person's Details

Name(Required)

First Last

Date of birth (if known)

Day

Month

Year

Age

Eligible age range: 15–25 years

Preferred Pronouns

Phone

Email

Address

Is it safe to contact the young person directly?

Yes

No

Unsure

If no, please provide the parent/guardian details below

Parent / Guardian Name

First Last

Parent / Guardian Phone

Parent / Guardian Email

Is the young person aware of this referral?

Yes

No

Unsure

Do they consent to being contacted by the Survivorship Program?

Yes

No

Unsure

(We aim to involve young people in decisions about their support wherever possible.)

Cancer & Treatment Journey (if known)

Diagnosis

Current Situation

In treatment

Recently finished treatment

In follow-up care

Ongoing or relapsed care

Not sure

Treating service (if known)

What support do you think would help them?

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 support

Urgency

Routine (okay to wait a few weeks)

Would like support soon (1–2 weeks)

Urgent (within a few days)

Urgency Reason

Anything else we should know?

This might include communication needs, family situation, cultural considerations, or anything else that may help us support the young person.

Consent & Understanding

Consent 1(Required)

I understand the Survivorship Program will aim to contact the young person directly where possible(Required)

Consent 2(Required)

I understand support is voluntary and the young person can choose whether to engage(Required)

Consent 3(Required)

I confirm the information provided is accurate to the best of my knowledge(Required)

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About CCRF

For forty years the Children’s Leukaemia & Cancer Research Foundation Inc (now trading as Child Cancer Research Foundation) has been raising funds for research into childhood cancers.

Suite 3/100 Hay Street, Subiaco WA 6008 +61 8 9363 7400 [email protected] ABN 42 030 465 053 Health Promotion Charity – DGR 1

The Child Cancer Research Foundation is operating under Charity Licence CC20305 — Children’s Leukaemia & Cancer Research Foundation Inc.

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