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.

Holiday Closure Canteen is closed 19 December – 5 January. Referrals submitted during this time will be reviewed on our return, and our team will contact you the week of 12 January 2026.

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? *