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About MND
What is MND?
Basic facts about MND
Have I got 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?
What do I do now?
Where can I find the information I need?
Coronavirus and MND
Coronavirus information
Covid-19 immunisation programme and people with MND
How to get registered as extremely vulnerable
Ask the Experts
Information for volunteers
Our Forum
Support and information
Our services
MND Connect Helpline
Benefits advice service
Equipment loan for MND
Financial support grants
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
How can I check if my treatment and care are appropriate?
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
Covid-19 immunisation programme and people with MND
How to get registered as extremely vulnerable
Ask the Experts
Get people with MND on the extremely vulnerable list
Information for volunteers
Our Forum
Get involved
Fundraise
Fundraise your way
Fundraising Events
#TakeoverMND
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
Become a campaigner
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
Our achievements
UK MND Collections samples
For researchers
Apply for funding
Resources for researchers
Noticeboard
Get involved in research
Take part in research
MND Register
MND research newsletter
About MND research
Stem cells and MND
Clinical trials
Animal research
Useful resources
MND Register
International Symposium
Professionals
Management of MND
Management by symptoms
Management by specific professions
Diagnosis of MND
Palliative and end of life care
Education and development
Calendar of events
Education bursary scheme
Special Interest Groups
Sign up for our Education newsletter
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
Register for the Audit Tool
NICE Guideline on MND
Sign up for our Education newsletter
Home
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.
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
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Gender
Male
Female
Non-binary
Prefer Not to Answer
Ethnicity
Please select:
A - British
B - Irish
C - Any other White background
D - White and Black Caribbean
E - White and Black African
F - White and Asian
G - Any other mixed background
H - Indian
J - Pakistani
K - Bangladeshi
L - Any other Asian background
M - Caribbean
N - African
P - Any other Black background
R - Chinese
S - Any other ethnic group
Z - Not stated
99 - Not known
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
Day
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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)
Known as/Preferred Name
Surname/Family 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
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2019
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2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2006
2005
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2003
2002
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1999
1998
1997
1996
1995
1994
1993
1992
1991
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1984
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1941
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1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
Male
Female
Non-binary
Prefer Not to Answer
Ethnicity
Please select:
A - British
B - Irish
C - Any other White background
D - White and Black Caribbean
E - White and Black African
F - White and Asian
G - Any other mixed background
H - Indian
J - Pakistani
K - Bangladeshi
L - Any other Asian background
M - Caribbean
N - African
P - Any other Black background
R - Chinese
S - Any other ethnic group
Z - Not stated
99 - Not known
Telephone (Home)
Telephone (Mobile)
Email
Preferred method of contact
Email
Post
Phone (Home)
Phone (Mobile)
Text message
Relationship to person with MND
GP details
GP full name
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Title
First
Last
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
Neurologist details
Neurologist full name
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Prefix
First
Last
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
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:
*
I confirm that this form has been completed in conjunction with, and with the permission of the person with MND.
Name of referrer
*
First
Last
Date
*
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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
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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.
Main Informal Carer name
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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. Membership is free and includes receipt of the quarterly magazine - Thumb Print.
No, I do not want to become a member.
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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
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. Please select all the ways you would like to be contacted below.
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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. Membership is free and includes receipt of the quarterly magazine - Thumb Print.
No, I do not want to become a member.
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
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MND Connect Helpline
Benefits advice service
Equipment loan for MND
Equipment Loan request form
Financial support grants
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Care centres and community services
Birmingham Care Centre
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Cambridge Care Centre
Liverpool Care Centre
Leeds Care Centre
London – Barts and London Care Centre
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London – The National Care Centre
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Newcastle Care Centre
Norfolk Care Network
North Midlands Care Network
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Sheffield Care Centre
Oxford Care Centre
South Wales Care Network
Southampton Care Centre
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Extra Mile Award
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About us
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Cornwall Branch
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Gloucestershire Campaigns
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Isle of Man MND Association
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About Jersey Branch
King’s Lynn Support Group
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Money 4 MND Northamptonshire Group
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Find support in your area
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Caring and MND: support for you guide
End of life: a guide for people with motor neurone disease
Living with motor neurone disease guide
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Emerging technology archive
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Christmas Card Competition 2020
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For further information and support contact our
MND Connect helpline
mndconnect
0808 802 6262
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