Make a referral

Refer yourself or someone you support to Canteen's services.

three young people having a conversation

After you submit this form, our Services team will review your referral and be in touch within 5 working days to discuss support options.

Urgent support

Canteen is a non-urgent service. For immediate help, call 111 or your local mental health crisis team.

REFERRAL FORM

Please select if you are...

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Are you 18 years or older?

Please select Yes or No *

Emergency Contact Details

*If you are under 18 years old please use parent/guardian details for your emergency contact.

Contact first Name *

Contact last Name *

Mobile Number *

Contact email *

Relationship to you *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Do you have any urgent mental health needs or is there anything putting you at risk at present? *

How did you hear about us? *

Referrer Details

Your first name *

Your last name *

Your email address *

Your mobile number *

Your organisation *

Your role *

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Rangatahi Consent

Has the rangatahi given consent for this referral? *

Rangatahi Emergency Contact

Contact first name *

Contact last name *

Contact mobile number *

Contact email address *

Relationship to rangatahi *

Does the rangatahi live with their parent/guardian? *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Are there any risk or safety concerns we should be aware of? *

Other details?

Referrer Details

Relationship to rangatahi *

Your first name *

Your last name *

Your email address *

Your mobile number *

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi

First name *

Last name *

Date of birth *

Ethnicity *

If other, please share ethnicity

Mobile number

Email address

Address *

Address 2

City/Town *

Post Code *

Rangatahi Consent

Has the rangatahi given consent for this referral? *

Rangatahi Emergency Contact

Contact first name *

Contact last name *

Contact mobile number *

Contact email address *

Relationship to rangatahi *

Does the rangatahi live with their parent/guardian? *

Rangatahi Cancer Experience

What best describes cancer experience? *

Enter other...

Cancer Type *

Reason for referral *

Are there any risk or safety concerns we should be aware of? *

Other details?

How did you hear about us? *