Family & Friends Group Therapy Self-Referral Form

Family and Friends Support Programme

8-Week Group Therapy Programme In association with Rareminds

This bespoke programme for family and friends only, provides a confidential and supportive space for you - alongside others who may be in a similar situation.

It offers facilitated opportunities to share experiences, explore common themes and discuss practical and emotional coping strategies

- promoting self-care as a vital component of well-being.

All sessions are co-ordinated and facilitated by trained, registered and experienced counsellors.

Please note all applications will be processed by the programme lead - who will contact you to discuss and/or confirm your place on the programme.

About You

First Name

Last Name

Contact phone number

Address: Town or City

Address: County

Address: Postcode

Which programme date are you applying for?

About your family member / friend

What is your relationship to the person with neuroendocrine cancer? eg spouse/partner/parent/child/etc:

How recently / long ago were they diagnosed with neuroendocrine cancer (length of time)

What kind of care / treatment are they currently receiving

Your health and support

Have you taken part in group therapy before?

YesNo

If Yes - what was your experience? If No - do you have any questions or concerns about taking part?

Where do you currently get support from? eg friends, family, etc

What do you hope to get from the group?

Do you have any pre-existing or current medical or mental health issues you are living with?

YesNo

Is there anything you think it would be useful for the group counsellor to know about your current physical and/or mental health?

Do you foresee yourself having any difficulty in attending each of the 8 week sessions of this programme? If Yes - please let us know what these might be

Would you be willing to take part in a post-programme online discussion ?

YesNo

Thank you : your submitted form will now be reviewed by the programme lead - who will contact you to either

confirm your place,
offer you a place on our waiting list if participant numbers have been reached
address any concerns you may have raised
and/or signpost you to other avenues of support if appropriate

Please note ; incomplete forms will not be processed

Please keep in mind that emails can sometimes be treated as junk mail

and can be diverted to spam folders, therefore do check these when possible,

in case one of our emails has been diverted there.

Contact Information