Request for support

PalAssist provides palliative care information and compassionate support to those dealing with a life limiting illness and those who care for them.

We aim to work with health professionals in providing palliative care information and support to their clients.

When you submit a request, we will make two attempts to contact your client within 5 business days, after such time, if unsuccessful, a PalAssist team member will leave a message (if able) and encourage the client to contact us.

Please complete the form below and a member of the PalAssist team will respond to your request

Referrer details

The request form is to be completed by a health professional on behalf of, and with the consent of, the client.

Name(Required)

First name Last name

Email(Required)

Phone(Required)

Location(Required)

Postcode(Required)

Patient details

Patient details(Required)

I have the consent of my client to share their personal information with PalAssist

This form cannot be submitted without client consent.

Name(Required)

First name Last name

Date of birth(Required)

dd/mm/yyyy

Gender(Required)

Age range(Required)

Postcode(Required)

Country of birth

Phone 1

Phone 2(Required)

Email(Required)

Preferred Contact Time(Required)

Client Type(Required)

Type of support requested(Required)

Condition/diagnosis(Required)

Can we identify as PalAssist when calling?(Required)

Yes

Additional Information

Your Personal Information and your Patient’s Personal Information is being or has been collected by Cancer Council Queensland (ACN 009 784 356) (“Cancer Council”, “we”, “us” or “our”) [cancerqld.org.au], so that a referral can be made for your Patient to PalAssist. Your Personal Information may be provided to third parties where required by law or so that such third parties may provide PalAssist with services. Please refer to Cancer Council Queensland’s Privacy Policy (which is available at cancerqld.org.au or on request by calling 13 11 20) for further details. We will take reasonable steps to ensure that such third parties deal with your information appropriately and only for Cancer Council purposes. Our Privacy Policy explains how you can contact us to access and correct your personal information or make a privacy complaint. You can contact us at privacyofficer@cancerqld.org.au or write to us at: Privacy Officer, Cancer Council Queensland, P.O Box 201, Spring Hill, Queensland, 4004.

Request for support

1800 772 273

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Email

Referrer details

Patient details