Self-Referral to Macmillan

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 Macmillan

Before You Start
Please 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 Office
About You
Name*
Title 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*
Housing Status*
Please State the Name of the Housing Association
Please Explain
Additional Information About You
By 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*
Type 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*
About Your Enquiry
Please Provide Details About Your Situation*
Please provide as much detail as you can about your issue or query, including any steps you have already taken
Our primary contact method will be to call you, please let us know if this will be difficult for you.
Further Information
If 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
Accepted 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
Phone
This field is for validation purposes and should be left unchanged.

Client - Self-Referral to Macmillan

Before You Start

About You

Additional Information About You

About Your Enquiry

Citizens Advice

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Client - Self-Referral to Macmillan

Before You Start

About You

Additional Information About You

About Your Enquiry

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