Financial Assistance Referral Form

Financial Assistance Referral Form
This referral form must be completed by a health professional on behalf of the client.
Referrer Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
Professional Title*

Social WorkerWelfare WorkerCancer Care NurseOther
Treatment Facility*

Bundaberg Cancer Care CentreCairns HospitalGreenslopes HospitalGold Coast University HospitalHervey Bay HospitalIpswich HospitalMackay Base HospitalNambour General HospitalPrincess Alexandra HospitalPA Hospital ROMCRedcliffe HospitalRoyal Brisbane & Women's HospitalRockhampton Base HospitalSunshine Coast University HospitalThe Prince Charles HospitalToowoomba Base HospitalTownsville HospitalOther
Client Information
Name*

First NameLast Name
Email*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Age Range*
Gender*

MaleFemaleOther
Does your client identify as Culturally and Linguistically Diverse?

YesNo
Does your client identify as Aboriginal/Torres Strait Islander?

YesNo
Type of Cancer*

BladderBlood/lymphaticBoneBrain TumourBreastColorectalGynaecologicalHead and neckKidneyLarynxLungProstateSkinTestisThyroidOther
Date of Diagnosis*

DayMonthYear
Date
Is your client currently participating in active cancer treatment?*

YesNo
Current Treatments*

SurgeryChemotherapyRadiation TherapyOther
Is your client experiencing severe financial hardship due to their cancer diagnosis and treatment?*

YesNo
Is your client at high risk of not participating in treatment due to financial hardship?*

YesNo
Has your client previously requested Financial Assistance?*

YesNoUnknown
Can you describe the financial hardship your client is experiencing?*
What are the key financial issues impacting your client?

Receiving a Centrelink PaymentWaiting for Centrelink PaymentNot workingLow incomeLimited family/social supportWaiting for PTSS refundNo PTSS approvalOther
What are the key treatment related costs impacting your client?*

FuelParkingCommunity Transport FeesAccommodationMedicationsMedical EquipmentNutritional SupplementsOther
What area are you seeking financial assistance for your client?*

AccommodationFuel CardFood Card
Has your client been approved for Patient Travel Subsidy Scheme?*

YesNo
Accommodation Check in Date

DayMonthYear
If dates are not confirmed, provide an estimate.
Accommodation Check out Date*

DayMonthYear
If dates are not confirmed, provide an estimate.
Which CCQ lodge or Accommodation facility is your client wanting to stay?*

Charles Wanstall Apex Lodge - Herston, BrisbaneEllis Lodge - South BrisbaneOlive McMahon Lodge - ToowoombaGluya Rotary Lodge - TownsvilleMarylyn Mayo Lodge - CairnsCentral Queensland Cancer Support Centre - RockhamptonOther
How would you like the card sent?*

Email digital card to clientEmail digital card to referrerPost card print-out to client
Please scan and email the full ‘printable’ Telstra bill to practicalsupport@cancerqld.org.au. Please allow 10 days for processing. Your client can call Telstra 13 2200 to request an extension if needed.

Alternatively post to:
Practical Support
Cancer Council Qld
PO Box 201
Spring Hill QLD 4004
Privacy Collection Statement

We take privacy seriously. We are committed to respecting your privacy and protecting your personal information. For more information on how we collect and handle your personal information please see our Privacy Collection Statement.
I agree to Cancer Council Queensland’s Privacy Collection Statement.
Please read the Financial Assist Guidelines.
Do you accept the Financial Assist Guidelines?*

I agree to Cancer Council Queensland's Financial Assist Guidelines
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Financial Assistance Referral Form

Referrer Information

Client Information