Peer Connect Referral Form

Peer Connect Referral Form

Peer Connect program offers free, confidential one-on-one phone support from trained peer mentors. The Peer Connect program enables people with cancer to be connect to a volunteer peer mentor who has been through their own cancer experience and are here to offer practical tips, emotional support, encouragement and insights.
Please note that * indicates a complusary feild
Name
Email
Postcode
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Area code
Mobile number
Format: 0000-000-000.
Do you identify as Aboriginal and/or Torres Strait Islander?
Do you identify as part of the LGBTQIA+ community?
Referred by
As a client, please confirm your consent / Referrers, please confirm you have obtained client consent to complete this referral
Current diagnosis
Cancer experience
Description of support need
Do you require an interpreter?
Do you have any accessibility or support needs?
Do you accept the Privacy Statement?

We take privacy seriously. We are committed to respecting your privacy and protecting your personal information. Cancer Council Queensland is collecting your information to facilitate services or products requested by you and/or to keep you informed about Cancer Council related activities. Unless you opt out, we may send you information about programs, products, services, fundraising or other activities that may interest you.
- We may share your information with other organisations so that they can provide us with services, or when required by law. If we share your personal information with others, we will take reasonable steps to ensure that they deal with personal information appropriately. It is possible that our use of these organisations may result in the disclosure of some of your information outside of Australia. You consent to your information being disclosed to a destination outside Australia; and you understand and acknowledge that we will not be held accountable, and you will not be able to seek redress under the Privacy Act in respect to such disclosures.
  
  For more information on how we handle your personal information, please see our General Collection Statement and our full Privacy Policy.
  
  If you do not agree to the disclosure of your personal information overseas, would like to access your information, or wish to unsubscribe from future communications from us, please email CRM Operations or write to us at CRM Operations, Cancer Council Queensland, PO Box 201, Spring Hill, QLD 4004.
  
  To make a privacy complaint, please contact our Privacy Officer.
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