Professional Referrer Details
Diagnosis and Medical Information
Has the patient been diagnosed with Duchenne Muscular Dystrophy?
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
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?
*