Referral Form

We need a few details so that we can provide you with the best possible support. Once you submit the form, someone from the Canteen Services team will be in touch as soon as possible (within 5 working days) to discuss support options. Please note that Canteen does not provide a crisis service. For emergencies, please contact 111 or for mental health advice and support please free text 1737.
Are you...

Rangatahi/young person details

Your pronouns
Your ethnicity
Your address

Are you 18 years or older?

Please select Yes or No

Emergency contact details

If you are under 18 years old please include your parent/guardian's details for the emergency contact.
Relationship to you

Referer details

Relationship to rangatahi

Rangatahi Details

Pronouns
Ethnicity
Address

Rangatahi emergency contact

If rangatahi is under 18 years old, please include parent/guardian details for the emergency contact.
Their relationship to rangatahi
Is your/their address the same as the rangatahi?
Postal address
Does the rangatahi live with their parent/guardian?
Parent/Guardian postal address

Rangatahi cancer experience

What best describes cancer experience?
Cancer type