The form below will allow you to refer yourself to our Macmillan service. Once we have received the form we will aim contact you within 5 working days.Client - Self-Referral to MacmillanBefore You StartPlease Confirm Whether or Not You are a Resident of Somerset Yes No Unfortunately, we are only able to offer our Macmillan service to clients that live in our local area of Somerset. As such we are unable to advise, and we would urge you to contact your Local Citizens Advice. You can find your Local CA by entering your postcode on the page here: Find Your Local Citizens Advice OfficeAbout YouName* Title MrMrsMissMsDrProf.Rev. First Last Date of Birth* Day Month Year Address* Street Address Address Line 2 City County Post Code Email Address* Phone Number*If Necessary, Can We Leave a Voicemail?* Yes No If Necessary, Can We Send You A Text?* Yes No If Necessary, Can We Send You A Letter?* Yes No Gender*Please select ...MaleFemalePrefers a different Term (Other)WithheldHousing Status*Please select ...OwnBuying Home(mortgage)Rent PrivatelySocial HousingLiving with Friends or FamilyOtherPlease State the Name of the Housing AssociationPlease ExplainAdditional Information About YouBy providing answers to the questions below you consent to Citizens Advice recording the special category personal data you are providing.Health - By answering this question you are providing consent to process this data*Please select ...DisabledLong Term Health ConditionNo Disability or Long Term Health ConditionUnknownPrefer Not to SayType of Cancer*Date of Diagnosis*Clinical Nurse Specialist (CNS) Name*CNS Phone Number*Ethnic Origin - By answering this question you are providing consent to process this data*Please select ...White - BritishWhite - EnglishWhite - ScottishWhite - WelshWhite - Northern IrishWhite - IrishWhite - OtherMixed - White & Black CaribbeanMixed - White & Black AfricanMixed - White & AsianMixed - OtherAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - OtherBlack or Black British - AfricanBlack or Black British - OtherOther - ArabOther - Any OtherUnknownPrefer not to sayAbout Your EnquiryPlease Provide Details About Your Situation*Please provide as much detail as you can about your issue or query, including any steps you have already takenOur primary contact method will be to call you, please let us know if this will be difficult for you.Further InformationIf you wish you may attach a files to provide us with further information. Please be aware this will not be encrypted when it is sent to us Drop files here or Select filesAccepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 5.Consent*When we record and use your personal information we only access it when we have a good reason, only share what is necessary and relevant, and we don’t sell it to commercial organisations. We need to record this information to help with your enquiry. We have a legitimate interest to do this. We will send a text message to the telephone number you have provided to confirm receipt of your completed enquiry. Please review our Information Charter if you’d like more information about how we’ll use your data Please tick here to confirm your consent PhoneThis field is for validation purposes and should be left unchanged.