NewReferralForm | bringinghope

Referral Form for Support

This form can be completed by the patient, or by a family member, friend, or medical professional supporting them.

We currently offer one type of support per patient (e.g. Hopefield House, financial support, or holistic support).

We will contact the patient by email to arrange the next steps. If the patient does not have an email address, please provide the contact details of someone who is happy to be contacted on their behalf and has given their consent. Please ensure the correct email address is provided.

If you do not have a referral code, you will need to upload evidence of the patients diagnosis. Please find a list of accepted evidence below:

A letter from a hospital consultant or oncologist confirming a cancer diagnosis

A hospital appointment or treatment letter that references cancer care

A letter from Macmillan Cancer Support, Marie Curie, Cancer Focus NI, or another recognised cancer charity confirming their involvement with the patient

A letter from the patient's GP confirming a cancer diagnosis

A prescription or medication letter referencing cancer treatment (e.g. chemotherapy, immunotherapy, radiotherapy)

An NHS or HSC cancer care plan, treatment summary, or patient pathway document

Evidence can only be provided as an image.

Do you have a referral code

Yes

Patient First Name

Patient Surname

Patient's Email

Confirm Patient's Email

Patient Phone Number

Date of Birth required

Select an Address

Which of these best describes the patient's current situation?

Patient has some financial resources but faces additional hardship due to treatment costs or reduced working hours

Patient is on a low income or state benefits and is experiencing significant financial strain.

Patient is in severe financial hardship, may be relying on emergency support, or has multiple compounding vulnerabilities.

Referral Code (For clinical referrals)

Upload Image

Medical Evidence (Details above)

I confirm that I am the patient and provide consent to be contacted, or that the patient has been informed that their details will be shared with Bringing Hope for support and has given their consent.

Email fields do not match, please try again.