Home to Treatment Referral Form

Home to Treatment Referral Form
Name

First NameLast Name
Professional Title

Allied HealthCancer Care NurseCCQ EmployeeMedical Officer / GPSocial WorkerWelfare Worker
Type a question
Referring Facility*

Brisbane Metro RegionBrisbane North RegionCairns RegionRockhampton RegionTownsville Region
Mater Adult HospitalPA HospitalRadiation Oncology PA Hospital Raymond TerraceRoyal Brisbane & Women's HospitalSt Andrew’s War Memorial HospitalThe Prince Charles HospitalOther
ICON North LakesNorth Lakes Cancer Care ServicesRedcliffe Hospital
Cairns HospitalCairns Private HospitalFar North Day HospitalIcon Cairns PrivateLiz Plummer Cancer Care CentreOther
Icon Cancer CareMater HospitalTownsville Hospital
Mater Private HospitalRockhampton Hospital - GenesisCare Radiation OncologyRockhampton Hospital - Medical Oncology
Phone Number*
Please enter a valid Australian phone number.
Email*
Service User Information
Does the service user have capacity to give their consent?*

Yes
Has the service user consented to being registered for this service?*

Yes
Can the service user provide proof of COVID-19 vaccination? (Please be aware that you may need to discuss alternate transport options with your patient.)

Yes
Name*

First NameLast Name
Primary Contact Person*

Service UserSupport Person, Advocate or Ally (chosen by the service user to represent them in matters relating to their support)
Has the service user given consent for Cancer Council Queensland to contact them for their support assessment and to discuss the service, and their transport needs?*

Yes
Mobile Phone Number (booking confirmations will be sent to this number)
Please enter a valid Australian phone number.
Home Phone Number
Please enter a valid Australian phone number.
Best Contact Time*

AMPMAny
If we contact you by telephone, is it okay to leave a message identifying as Cancer Council Queensland?*

YesNo
Does the service user give consent for Cancer Council Queensland to contact this person on their behalf for their support assessment and to discuss the service, and their transport needs?*

Yes
Has the service user been advised they will need to be present with this person for Cancer Council Queensland to complete the support assessment?*

Yes
Name*

First NameLast Name
Relationship to Service User*
Mobile Phone Number (booking confirmations will be sent to this number)
Please enter a valid Australian phone number.
Home Phone Number
Please enter a valid Australian phone number.
Best Contact Time (with service user present)*

AMPMAny
If we contact you by telephone, is it okay to leave a message identifying as Cancer Council Queensland?*

YesNo
Address (service user's pick up and drop off location)*

Street Address

Street Address Line 2

SuburbState

Post Code
Email (service information will be sent to this email address)*

Service User's EmailAlternative EmailN/A
Please provide an email*
Year of Birth*
Gender*

FemaleMaleTransgender MaleTransgender FemaleNon-BinaryPrefer not to sayOther
Does the service user identify as culturally and linguistically diverse?*

YesNo
Does the service user require an interpreter?*

YesNo
Please enter the language to be translated*
Does the service user identify as Aboriginal/Torres Strait Islander?*

YesNo
Eligibility
Cancer Category*

Blood and lymphaticBoneBreastDigestive organsEye, brain and other parts of central nervous systemFemale genital organsLip, oral cavity and pharynxMale genital organsMesothelioma and soft tissueRespiratory system and intrathoracic organsSkinThyroid and other endocrine glandsUrinary tractOther
Treatment Facility*

Brisbane Metro RegionBrisbane North RegionCairns RegionRockhampton RegionTownsville Region
Mater Adult HospitalPA HospitalRadiation Oncology PA Hospital Raymond TerraceRoyal Brisbane & Women’s HospitalSt Andrew’s War Memorial HospitalThe Prince Charles HospitalOther
ICON North LakesNorth Lakes Cancer Care ServicesRedcliffe Hospital
Cairns HospitalCairns Private HospitalFar North Day HospitalIcon Cairns PrivateLiz Plummer Cancer Care CentreOther
Icon Cancer CareMater HospitalTownsville Hospital
Mater Private HospitalRockhampton Hospital - GenesisCare Radiation OncologyRockhampton Hospital - Medical Oncology
Treatment being delivered*

ChemotherapyPalliative CareRadiationSurgicalOther
Please confirm that the service user is facing hardship in accessing their treatment including: financial hardship, limited family and social support, inability to self-drive and/or inability to access public or community transport.*

YesNo
Please confirm the service user is physically independent, able to mobilise and get in and out of a vehicle safely unassisted, and able to manage their own mobility aids if any.*

YesNo
Please indicate if the service user uses any mobility aids.*

NoneWalking StickWalking FrameWheeled WalkerWheelchairOther
Please indicate if the service user requires a support person to travel with them to access treatment?*

YesNo
Expected date from when transport is required*

DayMonthYear
Please select a date.
Please provide any additional information relevant to the service user's transport access and needs.
Privacy Collection Statement
We take privacy seriously. We are committed to respecting your privacy and protecting your personal information. Your personal information is being collected to facilitate providing Transport to Treatment Services, which are being requested by you. For more information on how we collect and handle your personal information please see our Privacy Collection Statement.
Do you accept Cancer Council Queensland's Privacy Collection Statement*

I agree to Cancer Council Queensland’s Privacy Collection Statement
If you are experiencing technical issues,
please email 131120@cancerqld.org.au or call 13 11 20.
Once submitted, please wait for the on screen confirmation message.
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Home to Treatment Referral Form

Service User Information

Eligibility

Privacy Collection Statement