Refer a family in need

Know a family with a child diagnosed with cancer or another life-threatening illness in our region needing support?
Send us their details by completing the form below and we will contact them.

Self Referral
You can also use this form if you have a child diagnosed with cancer or a life-threatening illness seeking our support, or feel free to just contact us.

Child's Details (if known)

Provide the information if known - if not just leave blank

Child's diagnosis

E.g. Cancer or other life-threatening illness

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Parent or Guardian's Details

Parent/Guardian's Name

First Name

Last Name

Parent/Guardian's Email

Parents/Guardian's Phone

Parents/Guardians home City, State and Postcode

Referrer's Details

Your Name

First Name

Last Name

Your relationship to the child/family

Your Organisation

Only required if you are submitting as a Social/Health worker

State

Postcode

Your Contact Number

Your Email

Would you like a copy of this form emailed to you?

Which of the following Applies

I have consent from the family that Country Hope may contact them directly

I have consent from the parents that Country Hope may contact them directly

Any other comments or details?

Let us know anything not covered above that will help us to provide support