PSPA Helpline Care Navigator (HCN) Referral Form

Patients Contact Details

Salutation

First Name

Last Name

Address Street

Address Town / City

Address County

Address Postcode

Email Address

Mobile Number

Home Phone

Preferred Phone

How did they hear about PSPA

Introduction From

Further Information about the patient

Sex

Pronouns

Ethnicity

Date of Birth

Diagnosis

Date of diagnosis (if known)

Patient Referral Information

Reason for referral:

Please inform us of any Health & Social Care Services in place/referred to:

Further information you think it would be useful for us to know:

Please confirm that the person has consented to the referral and to be contacted by PSPA:

YesNo

Patients GP/Consultants Information (if known)

Name of GP

GP Address Street

GP Address Town / City

GP Address County

GP Address Postcode

Name of Neurologist

Hospital Name

Neurologist Address Street

Neurologist Address Town / City

Neurologist Address County

Neurologist Address Postcode

Patients Communication Preferences

We would like to continue to keep in touch with you to tell you about the vital work we do for people with PSP or CBD, our fundraising activities, and opportunities to support us, as well as the services we provide.

Please select all the ways you would like to be contacted:

I would like to receive communications by email

I would like to receive communications by post

I would like to be contacted by phone

I would like to receive invites to any PSPA Support Groups

I do not wish to be contacted by PSPA

They can change their marketing options at any time by contacting us by email: consent@pspassociation.org.uk; telephoning us on 01327 322 410; or writing to us at PSPA, Margaret Powell House, 415a Midsummer Boulevard, Milton Keynes, MK9 3BN.

Patients Next of Kin Information

Name of the family member / carer

They are their:

NoK Relationship to Patient (e.g. Husband, Wife)

NoK Home Phone

NoK Mobile Number

NoK Email

Please add the family member/carers address if different from above:

NoK Address Street

NoK Address Town / City

NoK Address County

NoK Address Postcode

Heathcare Professional Completing the Form Details

Please note that your contact details will be added to our records and a Helpline Care Navigator (HCN) may get in touch regarding this referral. If you have any questions, please call 0300 0110 122.

HSCP Name

HSCP Job Title

HSCP Work Phone

HSCP Mobile Number

HSCP Work Email

HSCP Address Street

HSCP Address Town / City

HSCP Address County

HSCP Address Postcode

Date

Registered charity number England and Wales 1037087 and Scotland SCO41199

Contact Information