Make a referral – Children & Young People Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Address Cancer Information & Support Services, 2-2a Gwydr Crescent, Uplands, Swansea SA2 0AA. Telephone (01792) 655025 E-mail help@cancersupport.wales Child / Young Person DetailsName *Date of Birth *Age *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeContact Number *Can a message be left? *YesNoParent / Carer DetailsName of Parent / Carer / Contact Person *Address of Parent / Carer / Contact Person (if different from above)Address Line 1Address Line 2CityState / Province / RegionPostal CodeWho should be made contact with?Name(s) of people with parental responsibility *Do parents / carers agree to this child receiving counselling? *YesNoIf "no", please give details: *Is the child / young person aware of this referral? *YesNo aware number(s) Is Referrer DetailsIs this a self referral? *YesNoContact details of referrerIs this a referral by a family member of the referee? *YesNoContact details of family memberIs this a referral by an agency? *YesNoName of organisation *Name of referrer *Address of organisation *Address Line 1Address Line 2CityState / Province / RegionPostal CodeContact Number *Work email address *Please give names and contact numbers of any other agencies involved with this child / young person:Agency Name(s)Person(s) dealingContact number(s)Reason(s) for involvementReferral DetailsReason for referralSubmit
