Support Services Referral Form

Please complete this form to refer yourself or a patient to the Support Services team at Leukaemia & Blood Cancer New Zealand. Once your form has been received a member of the Support Services team will be in touch with the person being referred.

For general enquiries please see our Contact Us page or call us toll free on 0800 15 10 15.

 

Please tell us who you are:

Referrer details:

Sign up to receive news and updates from LBC

Patient details:

Ethnicity
New Zealand EuropeanMāoriSamoanCook Islands MāoriTonganNiueanChineseIndianUnknownOther (please specify)
Sign up to receive news and updates from LBC
Support person contact
Medical details


How we can help:

What are the patient's or family member's main concerns around the diagnosis at this time?
What LBC support would this person benefit from?
Information materials
Educational support
Emotional support
Support groups
Practical assistance
Other support agencies involved:
Other comments

Your details and/or the details of the person being referred will be stored securely by LBC and won’t be passed on to anyone else. View the full privacy policy.

Consent for referral given by:

I confirm that I have consent to share my patient or family members details.

* Required field