top of page

Healthcare Professional Referral

Professional Referrer Details

Patient Details

Date of Birth
Gender

Diagnosis and Medical Information

Has the patient been diagnosed with Duchenne Muscular Dystrophy?
Date of diagnosis
Does the patient have a child or is a sibling of a patient diagnosed with Duchenne Muscular Dystrophy?

Psychological Support Needs

Has the patient received any prior psychological or psychiatric support?
Does the patient or family currently have a psychologist or psychiatrist involved in their care?
Is there a current crisis or urgent need for psychological support?

Impact of Duchenne on Mental Health

Current Support Systems

Has the family sought out other charities or support organizations for assistance?

Preferred Method of Support

What type of psychological support would be most helpful?

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

bottom of page