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Register for financial assistance

Applicants must have the below form complete by one of the following: Oncology Specialist, Oncology Nurse or Hospital Social Worker.

Before completing the below form, please read the information below for applicants and health professionals and applicants eligibility.

Instructions for the applicant

Get this form filled by one of the following: oncology Specialist, Oncology Nurse or Hospital Social Worker

This form must be complete for all financial assistance. By having a health professional complete this form on your behalf, you are acknowledging that your personal details may be available on a strictly confidential basis, with other health professional and/treatment organisations in order from financial assistance to be authorised and approved.

After a health professional has submitted this application on your behalf, a member of our team will contact you directly to discuss available financial assistance.

Eligible assistance:

One off payment of up to $300 to assist with a gas, electricity or water bill
Food/fuel vouchers
Pharmacy account
Supplement drinks
Chemotherapy treatment
Initial costs of fertility preservation

Information for the Health Professional

In the below form, you will be asked to provide information about your patient's medical condition(s).

Please complete all the required questions in this form
Include your details and organisation
Please include treatment plan information with as much details as possible

After you have submitted the below form, a member of our team will contact the applicant directly to discuss available financial assistance.

Applicant eligibility

To be eligible for assistance through Rise Above the applicant must:

Reside in the Canberra/Queanbeyan Region
Have a current cancer diagnosis
Be receiving active treatment - chemotherapy, radiation, surgery and unable to preform your normal working duties or palliative
Not be fundraising privately, for example a GoFundMe fundraiser.

Patient application form

Please answer the following questions on behalf of the patient.

Patient's first name *

Patient's last name *

Date of birth *

Email *

Phone *

Address *

Are they of Aboriginal and/or Torres Strait Islander origin?

Are they a concession and/or a pension card holder?

Patient diagnosis *

Date of diagnosis *

Assessment *

Please describe the patient’s current treatment plan *

Treatment period *

Spouse or authorized representative (name and contact details required)

Details of children living at home (name, date of birth)

Referrer details

Referrer- First name *

Referrer - Last name *

Referrer - Title *

Referrer details - Hospital or organisation *

Referrer- Address *

Referrer - Phone *

Referrer - Email *

As the referrer, I confirm that all information provided it true *

Submit Submit

If you have any questions about this form, please call us on (02) 62971261 or email assistance@riseabovecbr.org.au

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