Online Support Group Referral Form
About You
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: 00000000000.
Town or City
*
Which age group do you belong to?
*
Under 24
25-34
35-44
45-54
55-64
65 -74
74 or older
About Your Cancer Experience
Which best descibes your situation? (Please select one)
*
I have been diagnosed with cancer
I am currently undergoing treatment
I have completed treatment
I am living with cancer as a long-term condition
I am a family member, carer or supporter
Other
What is your cancer type? (If you are supporting someone, please select their cancer type.)
Support Needs
What kind of support are you hoping for from the online support group? (Please tick all that apply)
*
Emotional support
Peer support and shared experiences
Information and understanding
Confidence navigating appointments or services
What is your preferred time for attending the online support group?(Please select all that apply)
*
Rows
Morning
Afternoon
Early Evening
Late Evening
Midweek
Weekend
No preference
Group Access and Safety
Are you able to join online sessions using Google Meet? (You do not need a Google account to join the session)
*
Yes
No
Background and Equality Monitoring
How would you describe your ethnicity?
*
Asian or Asian British (includes Indian, Pakistani, Bangladeshi, Chinese, or any other Asian background)
Black, Black British, Caribbean or African (includes African, Caribbean, or any other Black background)
Mixed or Multiple ethnic groups (includes White and Black Caribbean, White and Black African, White and Asian, or any other Mixed background)
White (includes British, Irish, Gypsy, Traveller, Roma, or any other White background)
Prefer not to say
Other
How would you describe your gender?
*
Female
Male
Non-binary
Prefer not to say
Other
Referral Information
How did you hear about Cancer Black Care? (Please select one)
*
GP or NHS Service
Macmillan
Community rganisation
Friend or family member
Social media
Other
Are you referring yourself, or has someone referred you? (Please select one)
*
Self-referral
Friend
Family member
GP
Hospital or healthcare team
Other professional
Other
Consent and Next Steps
Do you consent to Cancer Black Care contacting you about other related support services?
*
Yes
No
Do you consent to your information being stored securely in line with our privacy policy?
*
Yes
No
Submit
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