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 within 48 hours (where possible) 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 address

Are you 18 years or older?

Please select Yes or No

Parent/Guardian details

Emergency contact details

Relationship to rangatahi/young person

Referer details

Rangatahi Details


Rangatahi parent/guardian details

Is your address the same as rangatahi?

Rangatahi cancer experience

What best describes cancer experience?