Contact our SCI specialist clinicians

Are you:(Required)

A person with spinal cord injury

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

Details of referrer(Required)

First name Last name

Are you(Required)

If other, please specify(Required)

Tel(Required)

Email(Required)

Enter Email Confirm Email

Please let us know where your work is based

Fill in details of person with spinal cord injury below

Please provide some contact details below:(Required)

First name Last name

Address(Required)

Street Address Town/City County Postcode Country

Phone number(Required)

Email address(Required)

Enter Email Confirm Email

Date of Birth

Where are you currently located(Required)

Current location of SCI individual(Required)

Please provide the name and address details for this location.(Required)

Building name Address Line 2 Town/City County Postcode Country

What was the cause of the spinal cord injury?(Required)

If other, please specify(Required)

Type of injury(Required)

Complete/Incomplete(Required)

What year did the injury to the spinal cord occur?(Required)

Please provide the level of the injury. eg C6, T4, L1 etc(Required)

If other, please specify(Required)

Have you attended a spinal cord injury centre?(Required)

Yes

Have they attended a spinal cord injury centre?(Required)

Yes

Unknown

Name of spinal cord injury centre(Required)

Date of last attendance at spinal cord injury centre(Required)

How can we help?(Required)

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.(Required)

Yes please send me a copy of the form

No please don't send me a copy

Please enter the email address you would like the form to be sent to.(Required)

Email for return of form Confirm Email

Fill in details of person with spinal cord injury below

Our membership

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