Before completing our referral form please check you fit the criteria. 

1. The patient must be aged between 13-19 years of age.

2. The patient must have been diagnosed within the last 3 months (same criteria applies to those who have relapsed)

3. The referral must come from a healthcare professional who treats or works with the patient. 

If you fit all 3 criterias please complete the form and you will receive your Beat It Box within 2 weeks. 

Name of recipient *
Name of recipient
Date of birth *
Date of birth
Address *
Address
Sex *
Please let us know where the recipient would like their box delivered: in hospital or to their home.