• Person with MND
  • Main informal carer
  • Details
  • Children and Young People support
  • Support Volunteers
  • Confirmation
  • MND Association Details
  • Complete
Title
Click here to enter your address manually.
Preferred method of contact
If known.

There is no obligation to provide the below information but it is used anonymously and is invaluable in helping us determine to what extent different communities are and are not using our services and most importantly to then identify and remove barriers to participation. We are committed to becoming a fully inclusive organisation.

Please note:

The completion and submission of this form confirms that the person with MND has consented to the MND Association keeping a record of their details which will be stored securely in accordance with the requirements of Data Protection Regulations.

The following sections are optional and can be left blank if you prefer not to answer: Date of birth, Gender. 

The person that provides/would provide non-paid care and support on a regular basis (For example, Spouse, Partner, Parent, Family member/Friend)

Title
Click here to enter your address manually.
Preferred method of contact

Please note:

The completion and submission of this form confirms that the person with MND has consented to the MND Association keeping a record of their details which will be stored securely in accordance with the requirements of Data Protection Regulations.

GP details

Click here to enter your address manually.

Neurologist details

Click here to enter your address manually.

Referrer details

Name of referrer
Click here to enter your address manually.

Additional information

Please use this space to advise of any other relevant information that will assist us with supporting the person with MND. (e.g. speech difficulties, English not first language)

Children and Young People aged 18 and under (or up to 21 where the child or young person has additional needs). We offer a wide range of support for children and young persons who are affected by MND.

Would the person with MND like information about Children and Young People services?

Please detail below the name and date of birth of each child or young person requiring support - this is so age-appropriate information and support is provided.

The Association has a network of Support Volunteers who perform a vital role in supporting people affected by motor neurone disease – both those living with the disease and those close to them. All are volunteers who have been carefully selected and have undergone a thorough training programme. The Support Volunteers are based in the local community as members of a team and can offer support virtually, over the phone or via e-mail, or will visit them in their own home.

We also have a network of Branches and Groups and some offer support via meetings.
Please note that we do not have visitors available in every area of England, Wales and NI, however we can offer on-going support and help through regular contact with MND Connect (our Helpline) and in other ways if required.

Please tick the relevant boxes below:

We would like to know what information you are interested in receiving and how you would like us to contact you in the future. You can change your mind at any time.

Sharing information with local health and social care professionals and Association Support Volunteers

Person with MND's information choices

Our services
Would you like the Association to keep you updated on the services it provides and funds? This could include local newsletters on activities taking place in your area.
Updates
Would you like the Association to send you updates on the work being done locally and nationally including ways to get involved or help? These updates could include information about volunteering, campaigning or in supporting the Association financially.
Association membership
Would you like to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print? Note: We provide support to people affected by MND regardless of whether they are a member or not.
Communication preferences

We greatly appreciate your support and would like to keep in contact with you about our news, fundraising activities and appeals. To see how we use your data please read our Service Privacy Policy. Please select all the ways you would like to be contacted below.

Main informal carer information choices

Our services
Would you like the Association to keep you updated on the services it provides and funds? This could include local newsletters on activities taking place in your area.
Updates
Would you like the Association to send you updates on the work being done locally and nationally including ways to get involved or help? These updates could include information about volunteering, campaigning or in supporting the Association financially.
Association membership
Would you like to become a member of the Association and receive a welcome pack and the quarterly magazine Thumb Print? Note: We provide support to people affected by MND regardless of whether they are a member or not.
Communication preferences

Please see our service privacy policy for full details on how we use your information. Would you like to receive regular updates on the work we are doing, including details of ways in which you, your friends and family could help? These updates could include information about volunteering opportunities, ways of helping in our campaigning activities or in supporting the Association financially. Please select how you are happy to receive these communications:

You can stop receiving information or change your consent(s) at any time. Email [email protected] or call 0808 802 6262.