Cancer support referral

Cancer Council Nurses provide information and support to people affected by cancer. If you have a patient or carer that needs support, please fill in the referral form below and one of our cancer nurses will contact them to see how we can help. In addition, please let them know that they, or anyone affected by cancer, can call our nurses on 13 11 20 Monday to Friday, 9-5pm.

Health Professional details

First Name *

Last Name *

Phone *

Email *

Organisations *

Title *

Client details

First Name *

Last Name *

Gender *

Is your patient Aboriginal and/or Torres Strait Islander? *

Preferred language at home

Is an interpreter required

Postcode *

Phone

Mobile

OK to leave a message

Client Preferred time

Email *

Cancer Type *

Type of support required *

I confirm I am submitting this form on behalf of a person with cancer who, following my assessment and in my professional judgement requires support due to the impact of their cancer diagnosis.

I confirm the client is aware of and has consented to the use of their personal information for the purpose of Cancer Council SA processing this 13 11 20 information and support referral.

Privacy collection statement

Your privacy is as important to Cancer Council SA as it is to you. That's why any personal information you give us will be treated with respect and in strict confidence. Personal information is collected to process donations, issue tax receipts and to send you updates. We may disclose your information to agents, contractors and third parties who provide services to us, and in doing so we take reasonable steps to ensure any information held by our service providers is protected. A full copy of our Privacy Policy is at www.cancersa.org.au/privacy with details about how you can access and correct your personal information and how we handle any privacy complaints. Or call us on 1300 65 65 85 for more details about our commitment to your privacy.

To guard against fraud, please complete the following checkbox

Other referral options

The Cancer Council Pro Bono Program supports cancer patients, carers and bereaved carers with advice around legal issues and financial planning.

Health professionals can access a referral form here.

Clients can self-refer by calling Cancer Council on 13 11 20.

Cancer Council SA’s Financial Assistance Program provides support to individuals whose diagnosis of cancer is impacting on their financial situation.

Health professionals can access a referral form here.

Within the time constraints of a busy practice, it can be helpful to provide smoking cessation support by referring patients to Quitline.

Refer patients online or by downloading the medical software referral template.

You can download* and import the Quitline digital referral template into Medical Director, Best Practice or Zedmed.

You can refer your patient and their family/friends to information on the Quitline website or order a range of brochures for them to read through in their own time.

*WARNING: do not open the digital referral template file (*.rtf) with word processing software before importing. Doing so damages the format and requires you to repeat the download procedure.

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For more information on the referral process for other programs and services, please call 13 11 20 Cancer Council information and support.

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Cancer support referral