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Directory of cancer self help and support

By Susan Rodriguez,2014-06-26 20:00
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Directory of cancer self help and support ...

Directory of cancer self help and support

    and user groups

If you want to be in next year’s Directory of cancer self help and support and user

    involvement, please complete the following form and send it to the User Support

    and Involvement Administrator, Macmillan Cancer Support, 89 Albert Embankment,

    London, SE1 7UQ or email it to: resources@macmillan.org.uk.

    You will then be on our mailing list to receive our quarterly newsletter for people

    interested in self help and support and Cancer Voices. Your group will also be

    featured on the self help groups search on the Macmillan website.

GROUP NAME: _____________________________________________

CORRESPONDENCE INFORMATION

    Contact name: _____________________________________________

    Address: __________________________________________________

     __________________________________________________

    Town: __________________________________________________

    County: __________________________________________________

    Postcode: __________________________________________________

    Please tick if you DO NOT want your correspondence information to appear

    in the Directory or on Macmillan’s website ?

Counties covered by your group:

    ______________________________________________________________

Group email: ___________________________________________________

    Group website: _________________________________________________

Please list, if possible, up to 2 group members willing to take calls from the public:

    *Telephone/helpline* Email

    Name Day/times available

    number (if applicable)

*Phone numbers: We would advices against giving mobile phone numbers unless you have a dedicated

    group mobile phone.

MEETING PLACES

    Meeting Place 1 Meeting Place 2

Address: Address:

Town: Town:

County: County:

    Postcode: Postcode:

    Contact name: Contact name:

    Telephone: Telephone:

Email: Email:

    Disabled access: Y/N Disabled access: Y/N

Which information would you like to appear on Which information would you like to appear on

    Macmillan’s website/directory? Macmillan’s website/directory? (please tick one option): (please tick one option):

    ? Show town only ? Show town only ? Show full address ? Show full address

    If you have more than 2 meeting places please list on a separate sheet.

SERVICES / SUPPORT PROVIDED BY YOUR GROUP (please tick):

    Provision for deaf/hard Befriending Equipment loan of hearing

    Provision for visually Bereavement support Financial support impaired

    Cancer information Support from Health Provision for learning materials Professionals difficulties

    Cancer information materials in other Home visiting languages (please Telephone helpline specify): ____________ Hospital visiting ___________________

    Complementary Internet use available Transport service therapies

    Written resources in

    other languages (please Counselling specify):

    ___________________

    Spoken interpretation

     Dietary therapy service (please specify):

    ____________________

Other: ______________________________________________________________________

Cancer type (please tick):

     Anal Leukaemia Prostate

     Bladder Liver Skin

     Bone Lung Sarcoma

     Bowel (colon & rectum) Lymphoma, Hodgkin Stomach

     Brain Lymphoma, non- Testes

    Hodgkin

     Breast Melanoma Thyroid

     Cervix Mesothelioma Vagina

     Eye Myeloma Vulva

     Oesophagus Ovary Uterus

     Kidney Pancreas

     Larynx Penis

Other: ______________________________________________________________________

OR

Wider cancer focus (please tick):

     All cancers Children’s cancers Haematological

     Head and Neck Gynaecological Upper GI

Other: ______________________________________________________________________

Is you group specifically for (please tick):

     Everybody Children with cancer Young adults with cancer

     Adults Carers Relatives

     Young adults affected Men Women

    by cancer (eg. siblings,

    friends)

     Patients only Parents of children or Gay/Lesbian//Lesbian/Bi-

    young adults with cancer sexual/Transgender

     Diverse community Religious group (please

    group (please specify): specify):

    __________________ _____________________

Other: ______________________________________________________________________

Activities (max. 40 words):

    (e.g. Our group meets once a month. Sometimes we have talks by health professionals, other

    times we just meet for a chat to help support each other)

___________________________________________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    ___________________________________________________________________________________

    Is your group associated with a national umbrella support group? Y/N

If yes, which group? ___________________________________________________________

    Is your group associated with an NHS Trust? Y/N

If yes, which NHS Trust? ________________________________________________________

Would your group like to be on our mailing list to receive newsletters and invitations to

    our events? Y/N

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