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.

Are you... *

Rangatahi/young person details

Referer details

Your pronouns *

If other, please share your pronouns

Your first name *

Your last name *

Your date of birth *

Ethnicity

Your email address *

Your mobile number *

Your organization *

Your role *

Rangatahi consent

Has the rangatahi given consent for this referral? *

Rangatahi Details

Pronouns *

If other, please share the pronouns of the rangatahi *

First name *

Last name *

Date of birth *

Ethnicity *

Mobile number *

Email address *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Country *

Rangatahi emergency contact

First name *

Last name *

Mobile number *

Email address *

Their relationship to rangatahi *

Does the rangatahi live with their parent/guardian? *

Are you 18 years or older?

Please select Yes or No *

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? *

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

How did you hear about us? *