Self-Referral Form

Penny Brohn UK Preparing for Treatment Programme

Move more pictogram
Eat well icon with transparent background
A pictogram with a leaf in front of a sun

We know that getting ready for cancer treatment can feel overwhelming, and we’re here to help.

Our Preparing for Treatment programme offers free online support to help you feel more confident and prepared. This includes support with physical activity, nutrition, and emotional wellbeing – all tailored to what you’re going through.

Please complete this referral form, and we’ll get back to you within 2–3 working days.

Before we can invite you to join the programme, we’ll ask a few questions to check that our support is the right fit for you. This short screening helps us keep you safe and make sure you get the most benefit from what we offer.

Please don’t worry – even if some parts of the programme aren’t suitable for you right now, we can still support you in other areas.

If you’re unsure or would like to speak to someone before completing the form, feel free to get in touch at prehab@pennybrohn.org.uk – we’re always happy to help.

Consent
Name
Address

Cancer Diagnosis and Treatment

Past Medical History

(Please tick all that apply)
Past medical history
If you ticked yes to Myocardial Infarction, was it in the last 3 months?

Sign

I confirm that I have reviewed the Penny Brohn UK Preparing for Treatment criteria, and to the best of my knowledge, this patient is appropriate for assessment by the Penny Brohn UK team.
Referrer Name
Would you like to sign up for our newsletter?

Discover more from Penny Brohn UK

Subscribe now to keep reading and get access to the full archive.

Continue reading