Family & Friends Group Therapy Self-Referral Form

This dedicated group therapy programme if specifically for family and friends only.

If you have been diagnosed with neuroendocrine cancer, then either

our Newly Diagnosed or Living Well with Neuroendocrine Cancer Group Programme

would be more appropriate for you.

About You

First Name

Last Name

Contact phone number

Address: Town or City

Address: County

Address: Postcode

About your family member / friend

What is your relationship to the person with neuroendocrine cancer? eg spouse/partner/parent/child/etc:

When were they diagnosed with neuroendocrine cancer (date or length of time)

What kind of care / treatment are they currently receiving

Your health and support

What do you hope to get from the group?

Do you have any pre-existing or current medical or mental health issues you are living with?

YesNo

Is there anything you think it would be useful for the group counsellor to know about your current physical and/or mental health?

Have you taken part in group therapy before?

YesNo

If Yes - what was your experience? If No - do you have any questions or concerns about taking part?

Do you foresee yourself having any difficulty in attending each of the 8 week sessions of this programme? If Yes - please let us know what these might be

Thank you : your submitted form will now be reviewed by the programme lead - who will contact you to either

confirm your place,
offer you a place on our waiting list if participant numbers have been reached
address any concerns you may have raised
and/or signpost you to other avenues of support if appropriate

Please note ; incomplete forms may not be processed

Contact Information