Functional Neurological Disorders (FND) service - Professionals online referral form

This referral form is to enable your patient to access the Functional Neurological Disorders service. Before completing the form we encourage you to review the referral criteria below to ensure that your patient is eligible for support. If you need help filling in this form or have any questions, please contact the department secretary on 01782 275127.

To help us prepare for working with the patient we also encourage that you upload your most recent clinic letter at the end of this form.

• The patient must be aged ≥18.
• The patient must have a GP registered in Stoke-on-Trent (defined as GP practice postcode between ST1 to ST13).
• The patient has received an FND related diagnosis.
• The patient has consented for the referral.
• Diagnosis is documented in most recent clinic letter.