Refer a patient for specialist brain tumour support

Free, confidential support for brain tumour patients and families

Use this form to refer a patient to Brain Tumour Support for free, confidential emotional and practical support.

We work alongside clinical care and can support patients, families and carers from diagnosis onwards, including during treatment, recovery and longer-term adjustment.

Please ensure the patient has given consent for you to share their details before submitting this form.

Patient referral form

Please complete the form below to refer your patient to Brain Tumour Support's support groups or sessions. I (the Healthcare professional named below) confirm that providing this information complies with any applicable NHS data sharing protocols.

Patient details

Patient contact details(Required)

First name Last name

Does the patient have an email address?(Required)

Yes

Email address

Phone number(Required)

Can we leave a voicemail message if there is no answer?(Required)

Yes

Patient address(Required)

Address line 1 Address line 2 Town/city County Postcode Country

Diagnosis(Required)

Healthcare professional information

Healthcare professional name(Required)

Email address(Required)

Phone(Required)

Hospital name(Required)

Hospital trust(Required)

Sharing information

I confirm that providing this information complies with any applicable NHS data sharing protocols. I understand and confirm that in providing this information on behalf of the person(s) named above I have sought written or verbal permission for their details to be shared with Brain Tumour Support and for Brain Tumour Support to store and use them to make contact about the services indicated above.

Communication preferences

Please tell us how you would like us to keep in contact with you (tick all that apply)(Required)

Post

Phone

Your privacy

The information you’ve provided will only be used to contact your patient about our support services.

We will not use this or pass the details recorded in this form, or provided to us at a later date, to any other organisation without your permission.

As a healthcare professional completing this form on behalf of a patient, you must ask the patient for consent, and record that confirmation.

The information will be stored on our database for a maximum of five years. You can withdraw your consent at any time. To find out more about how we use your personal information, please read our privacy policy.