Self-Referral Form
Your Details
Full Name
*
First Name
Last Name
Date of Birth
/
Day
/
Month
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name & Phone Number
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About Your Caner Journey
Primary Cancer Diagnosis
*
Date of Diagnosis
/
Day
/
Month
Year
Date
Where are you currently on the Cancer Care Continuum
*
Please Select
Newly Diagnosed
Preparing for Treatment
Currently Receiving Treatment
Recovering from Surgery
Recently Completed Treatment
Long-Term Survivorship
Unsure
Current or PreviousTreatments
*
Please Select
Surgery
Chemotherapy
Radiation Therapy
Immunotherapy
Hormone Therapy
Targeted Therapy
Not Yet Started
Other
Additional Comments
Exercise & Support
What would you like support with?
Building strength
Reducing fatigue
Improving confidence with exercise
Preparing for treatment
Returning to exercise after treatment
Mobility and movement
Improving general wellbeing
Long-term exercise support
Unsure / Looking for guidance
Other
Additional Notes or Relevant Information
How would you describe your current exercise or activity levels?
Please Select
I currently exercise regularly
I do some light activity
I have exercised previously but not currently
I am completely new to exercise
Unsure where to begin
Do you have any current symptoms, injuries, or medical considerations we should be aware of?
Healthcare Team
Do you currently have support from any other healthcare providers?
GP
Oncologist
Physiotherapist
Nurse Specialist
Dietitian
Counsellor/Psychologist
Exercise Professional
Other
Additional Information
Is there anything else you would like us to know before we contact you?
Consent
*
I understand that exercise support will be individualised based on my health status, treatment stage, symptoms, and goals.
I consent to being contacted by The Exercise Oncology Collective regarding exercise support services.
Signature
Submit Referral
Submit Referral
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