CanTeen Referral Form
Please take a moment to read the referral guidelines under https://www.canteen.org.nz/join-canteen before completing the form below. The information provided is of course strictly confidential and is encrypted by SSL (similar to your Internet Banking security). Please note that the questions marked with an asterisk* are required.
Young Person's Details
Young Person's Name
Date of Birth
Young Person's Email
Young Person's Phone No.
Young person's cancer experience
Has a Parent with Cancer
Has a Parent who died from Cancer
Has a Sibling with Cancer
Has a Sibling who died from Cancer
Please select that which best describes the young person's situation.
Parent or Guardian's contact (if applicable)
Parent/Guardian's Phone No.
Address Line 1
Address Line 2
Referrer's Phone Number
Would you like a copy of this form?
Which of the following applies?
I have consent from the young person that CanTeen may contact them directly
I have consent from the parent that CanTeen may contact them directly
Please call me before calling the young person/parent
I believe this person will benefit from:
Overnight Psychosocial Programs
Face to Face Counselling
Canteen Online Peer Community
Which resources will be most useful (tick all that apply)
Any Additional Information
This field is for validation purposes and should be left unchanged.