Referral Form

Date _______________________________________

PATIENT INFORMATION

Name of Person being referred (First name only) __________________________________________________________

Contact Phone # ________________________________ Best time to Contact Morning Afternoon Evening

Cancer Patient _______ Family member _______

Phase of Treatment

Newly Diagnosed ______Post Treatment _____ Ongoing Treatment ____Survivorship ____ End Stage Cancer ____

Please indicate if your patient would like a counselor to meet with them at your facility. YES NO

Referred by_______________________________________________________________________________________

Medical Facility location ____________________________________________________________________________

Fax form to: Stillwaters Cancer Support Services, (262) 513-5731 or Mail form to: 434 Madison Street, Waukesha, WI 53188

Email questions to staff@stillwaterscenter.org or contact Danelle at (262) 524-4141

Stillwaters provides the following services for cancer patients, survivors, caregivers, family and friends: counseling, support groups, lifestyle programs,

educational workshops, peer to peer mentoring match and bereavement services.  All services are provided free of charge.