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About MND
What is MND?
Early signs of MND
How is MND diagnosed?
What causes MND?
Inherited MND
What is Kennedy’s disease?
Basic facts about Kennedy’s disease
Further support for Kennedy’s disease
Newly diagnosed?
Coronavirus and MND
Coronavirus information
Support and information
Our services
MND Connect Helpline
Benefits advice service for motor neurone disease
Equipment loan for MND
Financial support grants
Free Will writing services
Communication aids service
Care centres and community services
Online Forum
Local support
Find support in your area
Branches and groups
Area Support Co-ordinators
Association visitors (AVs)
Care centres and community services
Regional events
Living with MND
Mobility and movement
Personal care
Speech and communication
Swallowing, eating and drinking
Relationships and family
Emotions, thinking and behaviour
Breathing and ventilation
Health and social care
Types of care and who provides them
Needs assessment, home care and home adaptations
Benefits and financial support
Treatments and medication
Getting the right treatment or care with MND
Planning ahead
Carers and family
Support for carers
Support for family members
Bereavement support
Children and young people
Parents and guardians
Children aged 4 to 10
Young people aged 11 to 18
Information resources
Information for people with or affected by MND
Information in other languages and formats
Professional information
Research information sheets
Useful organisations and internet sites
Free or low cost apps
Coronavirus and MND
Coronavirus information
MND Matters: the MND Association podcast
Get involved
Fundraise
Fundraise your way
Fundraising Events
Find a fundraising event
Give in memory
Fightback Funds
Leave a gift in your Will
Corporate Partnerships
Trusts and Foundations
Fundraising Feedback and complaints
Make a gift aid declaration
Pay in your fundraising money
Raffle
Volunteer with us
Become a volunteer
Existing volunteers
Event volunteering
Campaign
Current campaigns
Campaign with us
Past campaigns
Policy
All-Party Parliamentary Group (APPG) on MND
Campaigning Toolkit
Cure Finders
Donate
Make a donation
Make a regular donation
Change your regular donation
Payroll Giving
Have you seen our latest appeal?
Become a Member
Research
Our research
Research we fund
Our researchers
Our research strategy
Using animals and stem cells in our research
UK MND Collections samples
For researchers
Resources for researchers
Noticeboard
The Researcher Newsletter
Apply for funding
Get involved in research
Take part in research
MND Register
MND Research List
Research News
Latest Research News
MND Research Blog
MND Research Newsletter
Research information sheets
Clinical Trials
What are clinical trials?
Treatment trials
Unproven treatments
MIROCALS
MND Register
International Symposium
Professionals
Management of MND
Information for specific professions
Diagnosis of MND
Dysphagia, nutrition and saliva problems
Respiratory symptoms in MND
Dysarthria
Muscle weakness and pain
Cognitive change and frontotemporal dementia
Palliative and end of life care
Education and development
Calendar of events
Webinars
Online Courses
Annual Stephen Hawking Foundation MND Lecture
Community of practice
Publications and Resources
Publications for professionals
Understanding MND training films
Information for people with or affected by MND
Information for carers and families
MND Just in Case kit
Best practice guidelines and pathways
Support for professionals
How we support professionals
Our services
Equipment loan service
Financial support grants
Communication aids service
MND Connect Helpline
Area Support Co-ordinators
Transforming MND Care Audit Tool
General information
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Support and information
Our services
Care Referral Form
Care Referral Form
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Please note:
The completion and submission of this form confirms that the person with MND has consented to the MND Association keeping a record of their details which will be stored securely in accordance with the requirements of Data Protection Regulations.
Person with MND
The following sections are optional and can be left blank if you prefer not to answer: Date of birth, Gender, Ethnicity, Sexual Orientation, Religion.
There is no obligation to provide this information but it is used anonymously and is invaluable in helping us determine to what extent different communities are and are not using our services and most importantly to then identify and remove barriers to participation. We are committed to becoming a fully inclusive organisation.
Title
Mr
Mrs
Miss
Ms
Mx
No title
First (and other) name(s)
Surname/Family Name
Known as/Preferred Name
Address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
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Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
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Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
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London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
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South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
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Angus
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Berwickshire
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Caithness
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Dunbartonshire
East Lothian
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Inverness-shire
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Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Date of Birth
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Gender
Male
Female
Non-binary
Trans
Other
Ethnicity
Please select:
A01 - English / Welsh / Scottish / N Irish / British
A02 - Irish
A03 - Gypsy or Irish traveller
A04 - Any other White background
B01 - White and Black Caribbean
B02 - White and Black African
B03 - White and Asian
B04 - Any other mixed/multiple background
C01 - Indian
C02 - Pakistani
C03 - Bangladeshi
C04 - Chinese
C05 - Any other Asian background
D01 - Caribbean
D02 - African
D03 - Any other Black/African/Caribbean background
E01 - Arab
E02 - Any other ethnic group
Prefer not to say
Unknown
Other
Sexual orientation
Please select
Heterosexual
Lesbian
Gay
Bisexual
Other
Religion
Please select
Christian
Muslim
Hindu
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Jewish
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Sikh
Other
Telephone (Home)
Telephone (Mobile)
Email
Preferred method of contact
Email
Post
Phone (Home)
Phone (Mobile)
Text message
NHS Number (if known)
Date symptoms started
Day
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Date of diagnosis
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Type of MND
Care Centre
Main informal carer
The person that provides/would provide nonpaid care and support on a regular basis (For example, Spouse, Partner, Parent, Family member/Friend)
Title
Mr
Mrs
Miss
Ms
Dr
Prof
Rev
First (and other) name(s)
Surname/Family Name
Known as/Preferred Name
Address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Date of Birth
Day
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Year
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
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2009
2008
2007
2006
2005
2004
2003
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1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Non-binary
Trans
Other
Ethnicity
Please select:
A01 - English / Welsh / Scottish / N Irish / British
A02 - Irish
A03 - Gypsy or Irish traveller
A04 - Any other White background
B01 - White and Black Caribbean
B02 - White and Black African
B03 - White and Asian
B04 - Any other mixed/multiple background
C01 - Indian
C02 - Pakistani
C03 - Bangladeshi
C04 - Chinese
C05 - Any other Asian background
D01 - Caribbean
D02 - African
D03 - Any other Black/African/Caribbean background
E01 - Arab
E02 - Any other ethnic group
Prefer not to say
Unknown
Other
Sexual orientation
Please select
Heterosexual
Lesbian
Gay
Bisexual
Other
Religion
Please select
Christian
Muslim
Hindu
Buddhist
Jewish
Atheist
Jain
Sikh
Other
Telephone (Home)
Telephone (Mobile)
Email
Preferred method of contact
Email
Post
Phone (Home)
Phone (Mobile)
Text message
Relationship to person with MND
GP details
Name of GP
Surgery address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Phone
Email
Neurologist details
Name of Neurologist
Neurologist work address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Phone
Email
Referrer details
Name of referrer
First
Last
Job title
Organisation
Address
Post Code
Postcode lookup only available for UK addresses
Find Address
Street Address
Address Line 2
City
Avon
Bedfordshire
Berkshire
Buckinghamshire
Cambridgeshire
Cheshire
Cleveland
Cornwall
Cumbria
Derbyshire
Devon
Dorset
Durham
East Sussex
Essex
Gloucestershire
Hampshire
Herefordshire
Hertfordshire
Isle of Wight
Kent
Lancashire
Leicestershire
Lincolnshire
London
Merseyside
Middlesex
Norfolk
Northamptonshire
Northumberland
North Humberside
North Yorkshire
Nottinghamshire
Oxfordshire
Rutland
Shropshire
Somerset
South Humberside
South Yorkshire
Staffordshire
Suffolk
Surrey
Tyne and Wear
Warwickshire
West Midlands
West Sussex
West Yorkshire
Wiltshire
Worcestershire
Clwyd
Dyfed
Gwent
Gwynedd
Mid Glamorgan
Powys
South Glamorgan
West Glamorgan
Aberdeenshire
Angus
Argyll
Ayrshire
Banffshire
Berwickshire
Bute
Caithness
Clackmannanshire
Dumfriesshire
Dunbartonshire
East Lothian
Fife
Inverness-shire
Kincardineshire
Kinross-shire
Kirkcudbrightshire
Lanarkshire
Midlothian
Moray
Nairnshire
Orkney
Peeblesshire
Perthshire
Renfrewshire
Ross-shire
Roxburghshire
Selkirkshire
Shetland
Stirlingshire
Sutherland
West Lothian
Wigtownshire
Antrim
Armagh
Down
Fermanagh
Londonderry
Tyrone
County
Postcode
Phone
Email
Additional information
Additional information
Please use this space to advise of any other relevant information that will assist us with supporting the person with MND. (e.g. speech difficulties, English not first language)
Children and Young People support
Children and Young People aged 18 and under
(or up to 21 where the child or young person has additional needs). We offer a wide range of support for children and young persons who are affected by MND.
No. of children and young people living with person with MND
No. of children and young people affected who live elsewhere
Please tick:
Person with MND would like information about Children and Young People services
Please detail below the name and date of birth of each child or young person requiring support -
this is so age-appropriate information and support is provided
Children and young people living with the person with MND
Children and young people affected and who live elsewhere
Support Volunteers
The Association has a network of Support Volunteers who perform a vital role in supporting people affected by motor neurone disease – both those living with the disease and those close to them. All are volunteers who have been carefully selected and have undergone a thorough training programme. The Support Volunteers are based in the local community as members of a team and can offer support virtually, over the phone or via e-mail, or will visit them in their own home.
We also have a network of Branches and Groups and some offer support via meetings.
Please note that we do not have visitors available in every area of England, Wales and NI, however we can offer on-going support and help through regular contact with MND Connect (our Helpline) and in other ways if required.
Please tick the relevant boxes below
Person with MND would like information about Support Volunteer services
Person with MND would like information about local Branch / Group support
Confirmation
Please tick:
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I confirm that this form has been completed in conjunction with, and with the permission of the person with MND.
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Would you like to receive a copy of this form emailed to you?
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If yes, please tell us which email address it should go to:
We would like to know what information you are interested in receiving and how you would like us to contact you in the future. You can change your mind at any time.
MND Association Services, Updates, Membership and Information
Person with MND's name
First
Last
Sharing information with local health and social care professionals and Association Support Volunteers
I agree that the Association can share information and discuss my needs with local Health and Social Care Professionals, Support Volunteers and services involved in my care and support.
Person with MND information choices
Our services
I would like the Association to keep me updated on the services it provides and funds. This could include local newsletters on activities taking place in my area.
No, I do not want to be contacted.
Updates
I would like the Association to send me updates on the work being done locally and nationally including ways to get involved or help. These updates could include information about volunteering, ways of helping in our campaigning activities or in supporting the Association financially.
No, I do not want to be contacted.
Association membership
I agree to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print. More details will be included in the welcome pack.
No, I do not want to become a member.
Note: We provide support to people affected by MND regardless of whether they are a member or not.
Communication preferences
We greatly appreciate your support and would like to keep in contact with you about our news, fundraising activities and appeals. To see how we use your data please read our
Privacy Policy
. Please select all the ways you would like to be contacted below.
Email
Post
Phone
Text message
Main informal carer information choices
Our services
I would like the Association to keep me updated on the services it provides and funds. This could include local newsletters on activities taking place in my area.
No, I do not want to be contacted.
Updates
I would like the Association to send me updates on the work being done locally and nationally including ways to get involved or help. These updates could include information about volunteering, ways of helping in our campaigning activities or in supporting the Association financially.
No, I do not want to be contacted.
Association membership
I agree to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print. More details will be included in the welcome pack.
No, I do not want to become a member.
Note: We provide support to people affected by MND regardless of whether they are a member or not.
Communication preferences
We greatly appreciate your support and would like to keep in contact with you about our news, fundraising activities and appeals. To see how we use your data please read our
Privacy Policy
. Please select all the ways you would like to be contacted below.
Email
Post
Phone
Text message
You can stop receiving information or change your consent(s) at any time. Email
mndconnect@mndassociation.org
or call
0808 802 6262
.
Support and information
Our services
Care Referral Form
Care Referral Form – Thank You
Care Referral Form – Consent
Our Online Forum
Wheelchair Support Service
MND Connect Helpline
Benefits advice service for motor neurone disease
Equipment loan for MND
Equipment Loan request form
Financial support grants
Reviewing our support grants
Communication aids service
Care centres and community services
Notts and Derby Care Centre – Derby Hub
Birmingham Care Centre
Bristol Care Centre
Cambridge Care Centre
Liverpool Care Centre
Leeds Care Centre
London – Barts and London Care Centre
London – King’s Care Centre
London – The National Care Centre
Manchester Care Centre
Middlesbrough Care Centre
Newcastle Care Centre
Norfolk Care Network
North Midlands Care Network
Northern Ireland Care Network
Notts and Derby Care Centre – Nottingham Hub
South West Peninsula Care Network
Lancashire and South Cumbria Care Centre
Sheffield Care Centre
Oxford Care Centre
South Wales Care Network
Southampton Care Centre
Sussex Care Network
Extra Mile Award
Nominations for Extra Mile Award
Local support
Area Support Co-ordinators
Association visitors (AVs)
Branches and groups
Bedfordshire Group
Birmingham and Solihull Group
Black Country Group
Cambridgeshire Branch
Events
Latest News for Cambridgeshire
About us
Fundraising
Meetings
Bristol and Bath Group
Cardiff and Vale of Glamorgan Branch
Central and East Lancashire Support Group
Cheshire Branch
Chiltern Branch
About the Chiltern Branch
Events
Fundraising
Cleveland Group
Colchester and North East Essex Group
Cornwall Branch
Coventry and Warwickshire Group
Derbyshire MND Support Group
Durham and Darlington Group
East Berkshire Branch
East Dorset and New Forest Branch
East London Group
East Kent Group
East Surrey Branch
East Sussex Branch
Exeter and East Devon Branch
Furness and District Support and Fundraising Group
Fylde and Wyre Group
Gloucestershire Branch
Gloucestershire Help and Support
Gloucestershire Branch News
Gloucestershire Branch Contacts
Gloucestershire Branch Events
Hambleton and Richmondshire Group
Herefordshire & Worcestershire Group
Hull and East Yorkshire Group
Isle of Man MND Association
Isle of Wight Branch
Jersey Branch
About Jersey Branch
King’s Lynn Support Group
Leicestershire and Rutland Branch
Lincolnshire Group
Manchester and District Branch
Merseyside Branch
Mid Kent Branch
Milton Keynes Branch
Money 4 MND Northamptonshire Group
North and East Hertfordshire Branch
Montgomeryshire Branch
North and West Cumbria Group
North & West Devon Fundraising and Support Group
North East Wales Branch
North Hampshire Group
North Lancashire and South Cumbria Branch
North Lincolnshire Group
North London Branch
North West Kent Branch
North West London Branch
North West Wales Group
North Wiltshire Group
Volunteering
Newsletters
Campaigning
Support Groups
Fundraising
Meet our volunteers
Northamptonshire Branch
Northumberland Group
Norfolk, Norwich and Waveney Branch
Northern Ireland Branch
Nottinghamshire Branch
Oxfordshire Branch
Oxfordshire Branch Past Events
Plymouth Group
Plymouth Group Committee
Plymouth Group Events
Portsmouth and South East Hants Group
Reading and West Berkshire Branch
Shropshire Branch
South and East Somerset Branch
South and West Somerset Branch
South East Wales Branch
South Essex Branch
South Hertfordshire Branch
South Lancashire Branch
South London Branch
South Wiltshire Group
South West Wales Branch
South Yorkshire Branch
Recycling Equipment
Events
Meetings
About Us
Branch news
About Us
Useful Information
Research Volunteering
About Us
Useful Information
Local Services
Fundraising
Southampton and Winchester District Group
Stamford Group
Staffordshire Support Group
Suffolk Support Group
Target MND – East London fundraising
Torbay and District Fundraising Group
Tyne and Wear Branch
West Dorset Branch
West Kent Branch
West London and Middlesex Branch
About Us
Recently diagnosed
Meetings
Events and fundraising
Useful information
Local Services
Borough of Ealing
Hammersmith and Fulham
Borough of Hillingdon
Borough of Hounslow
Borough of Kensington and Chelsea
Borough of Richmond Upon Thames
Borough of Westminster
Branch Activities
Want to make a difference?
Open Meetings
Branch updates
Fundraising
Events and fundraising
Guidelines for fundraising
Care and support
Request support from the branch
Other support available
Support Group Meetings
Local Services
Campaigns and awareness
West Surrey Branch
West Sussex North Branch
West Sussex South Branch
West Yorkshire Branch
Wirral Group
York Group
Yorkshire Coast Group
Yorkshire Dales Branch
Find support in your area
Submit your event
Health and social care
Benefits and financial support
Needs assessment, home care and home adaptations
Types of care and who provides them
Getting the right treatment or care with MND
Treatments and medication
Planning ahead
Living with MND
Personal care
Mobility and movement
Speech and communication
Swallowing, eating and drinking
Emotions, thinking and behaviour
Relationships and family
Breathing and ventilation
Information resources
What do all the words mean?
Information for people with or affected by MND
Find information about symptoms, treatment and care
Here’s everything we found
Caring and MND: support for you guide
End of life: a guide for people with motor neurone disease
Living with motor neurone disease guide
Publication dates
Information in other languages and formats
Useful organisations and internet sites
Free or low cost apps
Carers
Caring: Tell us what matters to you
Bereavement support
Support for carers
Support for family members
Children and young people
Young people aged 11 to 18
Support for children and young people
Information for young people
What’s new?
Get involved as a young person
Children aged 4 to 10
Christmas Card Competition 2021
Parents and guardians
Tell us about your Carers group and events
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For further information and support contact our
MND Connect helpline
mndconnect
0808 802 6262
Email us
Online Forum