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Healthcare Professional Referral
Professional Referrer Details
First name
*
Last name
*
Referrer Phone
*
Referrer Email
*
Relationship to the patient (Neuromuscular Consultant, Care Nurse, Healthcare Professional?)
*
Referring Organisation Name
*
Professional Role
*
Patient Details
Patient Full Name
*
Date of Birth
*
Day
Month
Month
Year
Gender
*
Other
NHS Healthcare Number (if applicable)
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Patient Phone
*
Patient Email
*
Diagnosis and Medical Information
Has the patient been diagnosed with Duchenne Muscular Dystrophy?
Date of diagnosis
Day
Month
Month
Year
Does the patient have a child or is a sibling of a patient diagnosed with Duchenne Muscular Dystrophy?
*
Name of Neuromuscular Consultant or Care Team Lead
*
Neuromuscular clinic/department
*
Psychological Support Needs
Has the patient received any prior psychological or psychiatric support?
*
If yes, please specify the type of support (counseling, therapy, psychiatry, etc.
Does the patient or family currently have a psychologist or psychiatrist involved in their care?
*
Please describe the psychological concerns or challenges the patient/family is currently facing (Please give as much information as possible)
*
What are the specific areas where support is needed? (e.g., anxiety, depression, coping with diagnosis, family dynamics, etc.) (Please give as much information as possible)
*
Is there a current crisis or urgent need for psychological support?
*
Impact of Duchenne on Mental Health
How has the diagnosis affected the patient’s mental health?
*
Cognitive function: Has the patient experienced difficulties in learning, memory, or decision-making?
*
Emotional well-being: Has the patient shown signs of anxiety, depression, or frustration?
*
Social relationships: How has DMD impacted the patient’s social interactions (e.g., with friends, peers, family members)?
*
Family impact: How has DMD affected the family’s emotional well-being and daily functioning?
*
Current Support Systems
Who are the key family members or caregivers involved in the patient’s care?
*
Does the family receive any external support services? (e.g., respite care, social services, etc.)
*
Has the family sought out other charities or support organizations for assistance?
*
Name of Organisation if known
Preferred Method of Support
What type of psychological support would be most helpful?
*
Online face to face (our standard)
Face to Face in person
Are there any barriers to accessing support?
*
Does the patient/family have any preferences regarding the psychologist (e.g., gender, language spoken, experience with neuromuscular conditions)?
*
Patient and Family Consent
Has the patient (and family if applicable) consented to this referral?
*
Does the patient/family consent to sharing their medical information with the charity?
*
Does the patient/family consent to being contacted by the charity for follow-up and support?
*
Additional Information
- Is there any other relevant information you would like to share to help us understand the patient’s needs better?
Submit
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