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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.

“You can also download a hard copy to refer patients and/or family members to Leukaemia & Blood Cancer New Zealand. If you prefer to fill out the hard copy form, please scan and email the form to supportservices@leukaemia.org.nz or post to PO Box 99182, Newmarket, Auckland.”

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:

    Yes, I want to receive news and updates from LBC

    Patient details:

    Ethnicity *
    New Zealand EuropeanMāoriSamoanCook Islands MāoriTonganNiueanChineseIndianUnknownOther (please specify)
    Yes, I want 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
    Preferred method of contact
    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 (if referring someone else):

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

    * Required field