proudly presents

The Canberra Brain Cancer Support Team

delivered by

REGISTRATION FORM

If you or a loved one have been diagnosed with brain cancer (benign or malignant) and reside in the ACT or surrounding regions, then we encourage you to complete and submit the form below to register to receive support from our Canberra Brain Cancer Support Team when the service becomes available in February 2025.

Upon receiving your application, we will direct our service delivery partner, the Peace of Mind Foundation, to contact you regarding your diagnosis and support needs. 

Please note: Some services may be subject to availability and funding.

We take your data and privacy seriously:
  • All information gathered will be kept confidential and used solely for the purpose of providing access to the Brain Cancer Support Team program. 
Patient information
Please complete the patient's details below
Date of birth
Gender
Brain Tumour Diagnosis
(name, type, location, or any other details you feel comfortable sharing)
Diagnosis date
Carer's information (if applicable)
Carer's Name
Carer's contact number
Carer's email address
Referrer's information (if applicable)
Referrer's name
Referrer's Organisation
Referrer's Position
Referrer's contact number
Referrer's email address
Support Service Request
Type of Service (required)
Please select all the services you require or are interested in



Please add any additional comments or queries here: (optional)
Have you encountered any challenges or difficulties related to accessing medical care and treatment for brain cancer in Canberra? (optional)
Please describe your experiences:
If you were to receive financial assistance, which of the following areas would you prioritise? (optional)











The Australian Brain Cancer Foundation Ltd