In sending us this form you are confirming that you understand you are being referred to Cancer Society Auckland Northland (CS), a non-government organisation dedicated to help reduce the incidence of cancer and ensure the best cancer care in our region. CS services are provided free of charge to people affected by any type of cancer.

Information on this form is used to determine the support required, which may include Community Liaison Nursing, Psychology Service, Volunteer Driving, and or Social Work Support.

Cancer Society’s services are unable to provide crisis intervention. For urgent support please contact the Crisis Team on 0800 800 717 or dial 111 in an emergency. If the primary issue isn't related to cancer or if a person needs a higher level of support than can be offered, the referral will be declined.

CS will conform to the Rules set out in the Health Information Privacy code regarding holding and using this information. It is also used to enable feedback after discharge, for quality purposes.

Please ensure all relevant details are completed on the form, as we need the information to provide safe and effective care.

- No one is obliged to utilise CS services. A patient may decline or withdraw at any time.

- All drivers in the driving service are volunteers.

- You may be contacted from time to time and given information regarding specific CS activities, for example by newsletter or group updates, unless otherwise requested.