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?*

Fuel CardFood Card
How would you like the card sent?*

Email digital card to clientEmail digital card to referrerPost card print-out to client
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.
Do you accept the Financial Assist Guidelines above?*

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

Referrer Information

Client Information