Referring someone

Connect yourself or someone you know or work with to specialist support from Canteen

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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.

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? *