Home to Treatment Referral Form

Radiation

Support during COVID-19

Cancer Council Queensland values the safety of our employees, volunteers, and especially those living with cancer. We are focused on doing what we can to prevent the spread of COVID-19 in Queensland.

The Home to Treatment service will continue to run with minor changes. We ask that all service users maintain social distancing (approx. 1.5m) between passengers and the driver, and limit the number of passengers wherever possible.

We have increased cleaning measures throughout the vehicle fleet and have provided hand sanitisers for use in all our vehicles.

Please be aware that all bookings are made without guarantee of service. If we cannot provide the service, we will advise you and our service users at the earliest opportunity so that service users can make alternative arrangements.

Home to Treatment

The Home to Treatment service aims to reduce the financial and emotional burden of cancer by providing transport to service users who are facing hardship in accessing their treatment.

These hardships may include:

• Financial hardship
• Limited family and social support
• Inability to self-drive
• Inability to access public or community transport

The service will transport eligible service users between their home and treatment facility within the Designated Service Area.

Home to Treatment is currently available in the following locations:

• Brisbane Metro
• Brisbane North Lakes
• Cairns
• Rockhampton
• Townsville

To access Home to Treatment, a service user needs to be referred by a health professional.

To refer to the service, the health professional must:

• Have read the Home to Treatment Guidelines and Home to Treatment FAQs
• Assess the service user as eligible for Home to Treatment
• Determine the service is suitable and will meet the service user’s needs
• Obtain the service users consent before referring to the service
• Complete and submit the online Home to Treatment Referral Form

Once the referral has been submitted and processed, the service user will be contacted by the Cancer Council 13 11 20 Information and Support service to conduct a support assessment and to discuss the service and their transport needs.

At the time of the call, 13 11 20 will provide the service user with the telephone number of their local Home To Treatment service and with information on how to make a booking.

Before completing the referral, please ensure you have read the Home to Treatment Guidelines and FAQ’s to ensure your clients eligibility and if the service is suitable for them

• Privacy Collection Statement

• Your Personal Information and your Service User’s Personal Information is being collected by Cancer Council Queensland (ACN 009 784 356) (“Cancer Council”, “we”, “us” or “our”) [www.cancerqld.org.au] to facilitate Transport to Treatment services requested by you for your Service User. Please refer to our Privacy Policy (which is available at the website above or on request by calling 13 11 20) for further details. Our Privacy Policy explains how you can contact us to access and correct your personal information or make a privacy complaint.

• I agree to Cancer Council Queensland’s Privacy Collection Statement*
  Yes

• Referrer Information

• Name
  First Name Last Name
• Professional Title
  Allied Health Cancer Care Nurse CCQ Employee Medical Officer / GP Social Worker Welfare Worker
• Referring Facility*
  Brisbane Metro Region Brisbane North Region Cairns Region Rockhampton Region Townsville Region
• *
  Mater Adult Hospital PA Hospital Radiation Oncology PA Hospital Raymond Terrace Royal Brisbane & Women's Hospital St Andrew’s War Memorial Hospital The Prince Charles Hospital Other
• *
  ICON North Lakes North Lakes Cancer Care Services Redcliffe Hospital
• *
  Cairns Hospital Cairns Private Hospital Far North Day Hospital Icon Cairns Private Liz Plummer Cancer Care Centre Other
• *
  Icon Cancer Care Mater Hospital Townsville Hospital
• *
  Mater Private Hospital Rockhampton Hospital - GenesisCare Radiation Oncology Rockhampton Hospital - Medical Oncology
• Phone Number*
  Please enter a valid Australian phone number.
• Email*

• Service User Information

• Does the service user have capacity to give their consent?*
  Yes
• Has the service user consented to being registered for this service?*
  Yes
• Name*
  First Name Last Name
• Primary Contact Person*
  Service User Support Person, Advocate or Ally (chosen by the service user to represent them in matters relating to their support)
• Has the service user given consent for Cancer Council Queensland to contact them for their support assessment and to discuss the service, and their transport needs?*
  Yes
• Mobile Phone Number (booking confirmations will be sent to this number)
  Please enter a valid Australian phone number.
• Home Phone Number
  Please enter a valid Australian phone number.
• Best Contact Time*
  AM PM Any
• If we contact you by telephone, is it okay to leave a message identifying as Cancer Council Queensland?*
  Yes No
• Does the service user give consent for Cancer Council Queensland to contact this person on their behalf for their support assessment and to discuss the service, and their transport needs?*
  Yes
• Has the service user been advised they will need to be present with this person for Cancer Council Queensland to complete the support assessment?*
  Yes
• Name*
  First Name Last Name
• Relationship to Service User*
• Mobile Phone Number (booking confirmations will be sent to this number)
  Please enter a valid Australian phone number.
• Home Phone Number
  Please enter a valid Australian phone number.
• Best Contact Time (with service user present)*
  AM PM Any
• If we contact you by telephone, is it okay to leave a message identifying as Cancer Council Queensland?*
  Yes No
• Address (service user's pick up and drop off location)*
  Street Address

  Street Address Line 2

  Suburb State

  Post Code
• Email (service information will be sent to this email address)*
  Service User's Email Alternative Email N/A
• Please provide an email*
• Year of Birth*
• Gender*
  Female Male Transgender Male Transgender Female Non-Binary Prefer not to say Other
• Does the service user identify as culturally and linguistically diverse?*
  Yes No
• Does the service user require an interpreter?*
  Yes No
• Please enter the language to be translated*
• Does the service user identify as Aboriginal/Torres Strait Islander?*
  Yes No

• Eligibility

• Cancer Category*
  Blood and lymphatic Bone Breast Digestive organs Eye, brain and other parts of central nervous system Female genital organs Lip, oral cavity and pharynx Male genital organs Mesothelioma and soft tissue Respiratory system and intrathoracic organs Skin Thyroid and other endocrine glands Urinary tract Other
• Treatment Facility*
  Brisbane Metro Region Brisbane North Region Cairns Region Rockhampton Region Townsville Region
• *
  Mater Adult Hospital PA Hospital Radiation Oncology PA Hospital Raymond Terrace Royal Brisbane & Women’s Hospital St Andrew’s War Memorial Hospital The Prince Charles Hospital Other
• *
  ICON North Lakes North Lakes Cancer Care Services Redcliffe Hospital
• *
  Cairns Hospital Cairns Private Hospital Far North Day Hospital Icon Cairns Private Liz Plummer Cancer Care Centre Other
• *
  Icon Cancer Care Mater Hospital Townsville Hospital
• *
  Mater Private Hospital Rockhampton Hospital - GenesisCare Radiation Oncology Rockhampton Hospital - Medical Oncology
• Treatment being delivered*
  Chemotherapy Palliative Care Radiation Surgical Other
• Please confirm that the service user is facing hardship in accessing their treatment including: financial hardship, limited family and social support, inability to self-drive and/or inability to access public or community transport.*
  Yes No
• Please confirm the service user is physically independent, able to mobilise and get in and out of a vehicle safely unassisted, and able to manage their own mobility aids if any.*
  Yes No
• Please indicate if the service user uses any mobility aids.*
  None Walking Stick Walking Frame Wheeled Walker Wheelchair Other
• Please indicate if the service user requires a support person to travel with them to access treatment?*
  Yes No
• Expected date from when transport is required*
   / Day  / Month Year

  Please select a date.
• Please provide any additional information relevant to the service user's transport access and needs.

• If you are experiencing technical issues,
  please email 131120@cancerqld.org.au or call 13 11 20.

• Once submitted, please wait for the on screen confirmation message.

• Submit
• Should be Empty:

Health Professional Cancer Network