Contact our SCI specialist clinicians

Are you:*

A spinal cord injured person
Making a referral on behalf of someone else who is spinal cord injured

Details of referrer*

First name Last name

Are you*

If other, please specify

Tel*

Email*

Enter Email Confirm Email

Please let us know where your work is based

Do you have consent to share the contact details of the person you are referring*

I have the consent of the person concerned to share their information

Details of spinal cord injured person*

First name Last name

Address*

Street Address Town/City County Postcode

Phone number*

Email address*

Enter Email Confirm Email

Please provide some contact details below:*

First name Last name

Address*

Street Address Town/City County Postcode

Phone*

Email*

Enter Email Confirm Email

Date of birth

NHS number*

Where are you currently located*

Current location of SCI individual*

If other, please specify

What was the cause of the spinal cord injury?*

What was the cause of your spinal cord injury?*

Type of injury*

What year did the damage to the spinal cord or the cauda equina occur?*

Please provide the level of your injury. eg C6 T4, L1 etc*

Please provide the level of injury.*

Have you attended a Spinal Cord Injury Centre?*

Yes
No

Have they attended a Spinal Cord Injury Centre?*

Yes
No
Unknown

Name of Spinal Cord Injury Centre attended*

Date of last attendance at Spinal Cord Injury Centre*

How can we help*

Spinal Injuries Association (SIA) understands that your privacy is important to you and that you care about how your personal data is used, stored and shared. You can find out more about how SIA uses your data and protects your privacy here: www.spinal.co.uk/sia-privacy-policy. More details about the information collected by the SCI Specialist Nurses Service is available at www.spinal.co.uk/your-personal-information/

Our membership

We consider all of our service users to be members of SIA, for life and for free. As the expert, guiding voice for life after spinal cord injury, we aim to reach everyone with a spinal cord injury, their families, and professionals and organisations in our sector, to tackle whatever barriers they face, and to connect them to all the help and support they need to flourish in their lives, in the way they want and choose.

When you submit this form a copy of it can be sent to you. Please let us know if you would like to receive a copy of this form.*

Yes please send me a copy of the form
No please don't send me a copy

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Email for return of form Confirm email

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