Support Services Referral

Support services referral
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Name*

First NameLast Name
Phone Number*
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Email
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Date of birth

DayMonthYear
Date
Gender
Are you of Aboriginal and/or Torres Strait Islander origin?
Are you a:
Diagnosis

AmyloidosisMyeloproliferative neplasms (MPN)Blood disorder e.g. aplastic anaemiaMyelodysplastic syndrome (MDS)MyelomaLeukaemiaLymphomaOther
Could you tell us which services you're interested in? (tick all that apply)

AccommodationTransport assistanceEmotional supportBereavement supportFinancial assistanceEducation and informationPeer support groupsI'm not sureOther
Do you have any additional comments in relation to this referral?
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Christmas closure information, Please Read.

Leukaemia Foundation Offices are now closed and will re-open again on Monday, 5 January 2026.

Any referrals received will now be reviewed by our Health Services Team when we return on Monday, 5 January 2026.

Please note, Leukaemia Foundation are not an acute health, emergency, or hospital service. If you have health concerns, please contact your treating team or general practitioner. If you are experiencing an emergency or your life is in danger, please contact 000. Leukaemia Foundation does not provide crisis support. If you are in immediate need of crisis support, please contact one of these organisations: Lifeline – 13 11 14 Beyond Blue – 1300 22 46 36 Mensline – 1300 78 99 78 OzHarvest Food Relief

We would like to take this opportunity to thank you for your ongoing support and wish you and your loved ones a safe festive season.

Your privacy is important to us and we treat your personal information with confidence. To learn more about how and why we collect and use any personal or sensitive information about you, please read our notification statement.
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Support services referral

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