Application form

If you have been diagnosed with a PRIMARY brain tumour then we encourage you to please fill out and submit the form below to apply for our support services. Upon receiving your application, we will be in contact regarding your medical diagnosis and will require a statement from your doctor or treating hospital to confirm your diagnosis if you have self-referred.

Please note: Some services may be subject to availability within your region and funding.

Patient Information

Patient's Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Number

Primary Brain Tumour Diagnosis

Diagnosis date

Just month and year if possible

Carer's Information (if applicable)

Carer's Name

First Name

Last Name

Carer's Contact Number

Carer's Email Address

Referrer's Information (if applicable)

If you are referring a patient please fill out this section below

Referrer's Name

First Name

Last Name

Referrer's Organisation

Referrer's Position

Referrer's Contact Number

Referrer's Email Address

Support Service Request

Type of Service

if you select more than one, we can help determine the appropriate services

National Advocacy Service (NDIS + Centrelink + Local Supports)

Resources - The Survivorship Diary

Support Groups

Online Counselling

Financial Assistance

Wills & Power of Attorney (Barwon Region only)

Brain Cancer Support Worker Follow Up (Barwon Region Only)

Weekend Retreats

Mark Hughes Foundation Patient Pack

Reason for Support Service Request

Please provide a brief description outlining your situation and also please include your primary brain tumour diagnosis and diagnosis date.

Application form

CONTACT US

PHONE: 0408 448 223

EMAIL: info@peaceofmindfoundation.org.au

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