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Referrals to Can-Survive UK
Professionals can refer an individual to Can-Survive UK
using the form below
.
Alternatively, to discuss making a referral, please get in touch
by phone or email.
Referrer's details
About you
Source of referral
(Required)
General Practice
Hospital
Other service
Practice name
(Required)
Your name
(Required)
Name of hospital
(Required)
Your name
(Required)
Name of service
(Required)
Your name
(Required)
Service user's details
About the person you are referring
Their first and last names
(Required)
Their address
(Required)
Their contact details (please supply phone number, email address or both)
(Required)
Their date of birth
(Required)
Cancer diagnosis
(Required)
Date of diagnosis
Any other relevant health information
Their next of Kin (name and relationship)
Contact phone number for next of kin
About the referral
The person is interested in
(Required)
Support group
One-to-one therapies
Self-management programme
Wellbeing activities and workshops
Advice, information, advocacy
Not sure
Their preferred location
(Required)
Kath Locke Centre, Hulme
Langworthy Cornerstone Community Centre, Salford
Limelight Wellbeing Hub, Old Trafford
Not sure
Consent
(Required)
I confirm that the patient has given verbal consent for this information to be passed on to Can-Survive UK
