Tele Counselling

Thank you for making use of our CANSA Tele Counselling service. Please complete the online form below to assist us in making an appointment with one of our professional counsellors for you. We will confirm your appointment via email.

Name*

Surname*

Age

Language you would prefer to receive counselling in:*

Alternate language you are able to receive counselling in:*

Time of day suitable for counselling sessions:*

Would you prefer to speak to a male or female counsellor:*

Province*

City/Town*

Cell Number*

Alternate contact number

Email*

Are you:*

I am an ostomate (wear a stoma bag)*

Yes
No

Why do you wish to receive counselling? Provide a brief description (optional)

Religion (if you wish to disclose)

By submitting your details, you agree to receive communication from The Cancer Association of South Africa (CANSA).

We undertake to treat your information confidentially and will not pass them on to third parties.

Consent*

I herewith give permission that personal information which is required may be stored on paper-based and/or digital systems of CANSA and may be used for the purpose of the project / service required. I consent to CANSA using my data for statistical purposes (no personal information will be used). Statistics will be used for internal research and for external stakeholders’ information only.

Yes*

Name

This field is for validation purposes and should be left unchanged.

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