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House of Healing — Cancer Support Referral

Who is completing this referral?

If referring someone else: your telephone number or email

If referring someone else: your name, relationship or role, and organisation

Full name

Date of birth

Postcode

Telephone number

Email address

Preferred method of contact

Best time to contact

May we leave a voicemail?

Cancer diagnosis / type

Where are you currently in your cancer pathway?

Current or planned treatment

What support would you like to discuss?

Please tell us briefly what support is needed or what feels most important right now

For example: communication or accessibility needs, mobility, interpreter needs, preferred contact arrangements, or anything that would help us make contact sensitively.

Is there anything we should know before contacting the person?

Is there any immediate concern about the person's safety or wellbeing?

If yes or unsure, please give brief details

Name of person completing form

Explicit consent to use health information — HC-v1

Health-information consent evidence — PN-v1 / HC-v1: who gave consent, the date and how it was given. For self-referral, state that you are giving consent through this form today. For a referral on someone else’s behalf, record the person’s explicit agreement and your authority to submit. Do not include unrelated health details.

<p>Enter your own email address if you would like an acknowledgement. If you are referring someone else, enter your email, not theirs. We will send a receipt only, without the referral answers. Leave blank if you do not want an email receipt.</p>

Your email address for a referral receipt (optional)

House of Healing Collective CIC provides practical, emotional and complementary wellbeing support for people affected by cancer. Once we receive this referral, a member of our team will contact the person referred for a short telephone consultation to understand their circumstances and discuss the most appropriate support available. Completing this form does not guarantee a funded place; support is offered according to individual need, suitability and availability.

About this referral

Person being referred

Cancer information

Support requested

Contact and access needs

Privacy notice PN-v1 — 23 September 2026
Email automation update — 24 September 2026
House of Healing Collective CIC is responsible for your referral and support records. Contact Suzi at contact@houseofhealing.live with privacy questions or requests.
We receive the information you or your authorised referrer provide: identity and contact details, health and treatment information, support and access needs, safety concerns and consent records. We also record telephone discussions, support decisions and follow-up. Email and NHS number are optional. Required information helps us review and respond to your referral; contact Suzi if you cannot provide it.
We use this information to review your referral, contact you, discuss suitable support, manage waiting lists and arrange the support you choose. Funding and support decisions are made by a person, not automatically. We rely on consent under UK GDPR Article 6(1)(a) and explicit consent for health information under Article 9(2)(a). You can withdraw consent through Suzi at the address above. Withdrawal does not affect earlier lawful use; Suzi will explain what support can continue without that information.
Suzi manages the records in Plinth and manual email through 123 Reg. HoH also uses Make to check referral submissions and arrange automatic receipt emails. Make processes the submitted referral answers, including contact and health information, to extract the optional receipt email address and check for duplicate sends. Only that email address and the acknowledgement text are passed to Brevo to send the receipt; health answers are not included in the email. Make retains referral IDs for duplicate prevention. Leaving the optional receipt email field blank prevents a receipt email. These suppliers process information to provide their services. Relevant information is shared with a selected practitioner or outside organisation only after discussing it and recording your separate agreement, unless disclosure is required or otherwise permitted by law, for example to respond to a serious safety concern. Such disclosure requires a separate assessment; this consent is not blanket permission.
HOH keeps each referral and its linked support records for two years from that referral date, with a manual review for deletion. A later referral has its own date and record. This is the operational retention period, not a promise that all supplier backup copies disappear that day. Plinth’s published policy describes recovery logs for 90 days and backups for up to one year after deletion. Supplier processing may involve the UK, EU or other countries under applicable transfer safeguards; contact Suzi for the current supplier details.
You can ask for access, correction, deletion or restriction of your information and, where applicable, portability or object to its use. Rights depend on the circumstances. You can complain to Suzi or the Information Commissioner’s Office at https://ico.org.uk/make-a-complaint/.

Explicit consent to use health information (HC-v1). Read the notice above before choosing. If consent or authority is unclear, do not submit health information; contact Suzi to discuss the next step.

Consent and declaration