Neurological Physiotherapy Self-Referral :: Chesterfield Royal Hospital

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Date of birth Required

NHS No: Required

Click on this link to find your NHS No: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Where have you lived for the last 12 months? Required

If outside the UK OR UK plus another country...

Do you have any special requirements? e.g. interpreter?

Do you have a EHIC card or other document to show that you're entitled to free NHS care?

None

Yes - -Please bring with you to your appointment

If your GP surgery is not listed, please call us on 01246 512173. We can then contact your GP to check they are happy for us to accept your self-referral.

Your GP details Required

Please list current medications including pain relief Required

Are you physically able to attend your appointment at Chesterfield Royal Hospital? If no, please contact your GP for a Community Referral Required

Yes

Do you have a neurological condition which has been diagnosed by a neurological consultant? If no, please speak to your GP Required

Yes

What is your neurological condition? Required

Multiple Sclerosis

Parkinson's Disease

Stroke

Ataxia

Cerebral Palsy

Peripheral Neuropathy

Peripheral Nervous System Condition

Functional Neurological Disorder

Other

If other, please specify

What is the name of your Consultant?

If you have answered yes to Functional Neurological Disorder:

The consensus among specialists working with people with functional neurological disorders is that a multidisciplinary approach is important to successful management. This includes a combination of physiotherapy and psychotherapy or mental health support. Please be aware that we will discuss these principles in more detail at your initial assessment and as part of goal setting for treatment.

As part of your diagnosis of functional neurological disorder have you been referred for psychological therapy or other mental health support?

Yes

If you answered no, please consider accessing your local mental health services via: Contact us/refer yourself :: Derbyshire Healthcare NHS Foundation Trust (derbyshirehealthcareft.nhs.uk)

Please note we may need to contact you to discuss this further prior to accepting a referral

Unsure? Please liaise with your GP or neurologist to confirm if a referral has been made prior to submitting your self referral.

Please describe your current issue which requires physiotherapy and identify your goals for treatment. (Please note that referrals will not be accepted without specific, identifiable goals as treatment programmes will be focused on these) Required

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Neurological Physiotherapy Self-Referral

If outside the UK OR UK plus another country...

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