DRS - Diagnosed Person Information

Diagnosis & Treatment Details

Date of Diagnosis/ Relapse *

Diagnosis/ Relapse Details *

Treatment *

Trust/ Region *

Main Hospital/ Treatment Centre *

Treatment Details *

IMPACT OF CANCER WITHIN THE FAMILY *

Briefly describe how the cancer diagnosis has impacted your family and the types of support that might be helpful from Cancer Fund for Children. E.g. (Individual support at home, short break, group support, parental support, hospital support, phone support).

Parent/Spouse/ Carer

Please provide contact details for the main contact(s) for the Diagnosed Person. If the main contact is the Diagnosed Person, add the details and select 'Self' in the relationship options.

Primary Contact

Title *

First Name *

Surname *

If the address of the Primary Contact is the same as that of the Diagnosed Person,
Click the 'Fill in Address' button.

Address 1 *

Address 2

Town *

Country *

County *

Post Code/ Eircode

Email *

Mobile *

Gender *

Relationship to Diagnosed Person *

Secondary Contact

Please provide details of a secondary contact for the diagnosed person.
If there is no secondary contact information, this section may be left blank.

Title

First Name(s)

Surname

Address 1

Address 2

Town

Country

County

Post Code/ Eircode

Mobile

Gender

Relationship to Diagnosed Person

Children, Teenagers, Young Adults living in the Family home * Please provide details of other children in the family home, if known at the time of referral.
If not known, this section can be left blank

Consent *

I confirm that I have obtained the appropriate consent required to make this referral.

Commitment

CFFC is committed to making sure that any information we hold about you will be collected, stored, and used in accordance with The Data Protection Act 2018 and General Data Protection Regulation 2016/679 (GDPR). This means that we adhere to the data protection principles of only holding information about you that is relevant to our work with you, that we make sure the information that we hold is accurate, up to date, secure, and only kept for as long as we need it. Should you have any questions relating to this notice or our processing of personal data, please email services@cancerfundforchildren.com.

The Purposes of the Processing of Personal Data

Provide you with our services.
Monitor and evaluate the impact and outcomes of our services and improve them accordingly.
Communicate with you about our services.
Comply with our legal and regulatory obligations and safeguard your rights and interests.