Neurology Referral Form

Please ensure this form is complete and accurate.

We are not a rapid response service and must not be considered when preparing a discharge plan from hospital or for patients requiring urgent treatment.

All patients must fulfil the following criteria:

• Be registered with a Worcestershire GP or patient has requested to access this service through patient choice
• Have a neurological diagnosis with the cause of their current symptoms being neurological in nature
• Have specialist needs that are not being met or able to be met by other existing services

If you want to refer to the Epilepsy Service, please don’t complete this form. Please contact: wah-tr.neurologysecs@nhs.net

If you want to refer to Speech and Language Therapy, please don’t complete this form. Please contact: Whcnhs.adultsltreferrals@nhs.net

Referral Details

Note: Questions marked by * are mandatory

*This is a mandatory field. Referrer Name:

*This is a mandatory field. Job Title:

*This is a mandatory field. Referrer Phone Number:

*This is a mandatory field. Referrer Email Address:

*This is a mandatory field. Date of Referral:

If you are referring for postural advice and support, can photos be consented and sent to the cnrt email with email titled “referral information for patient name and NHS number”. This will assist the triage process.