London Support Centre Survey – Helen Rollason Cancer Charity

Name

First

Last

Daytime phone number

If we were able to offer you a reflexology treatment do you feel you would you like to book an appointment?

Yes

Maybe

This does not commit you to an appointment. We appreciate personal circumstances and thoughts change, but it assists HRCC with calculating staffing levels required.

Would you need any support getting into the Centre/Treatment Room? If so what can we do to help you?

We have received guidance that we cannot offer treatments to anybody who is extremely vulnerable, or anybody living in the same household as a person who is extremely vulnerable. Please tick if any of these conditions are applicable to you or somebody in your household.

If you have ticked yes to any of the above that relate to a course of treatment, when are you expecting that treatment to be completed?

We understand that your needs may have changed and you may feel that you no longer wish to use our services at this time. If you wish to be removed from our current client list please tick the box below. Note: If you tick this box it would not prevent you from accessing our services in the future.

Thank you for this information. If we are able to offer you an appointment we will be in touch soon.