Request Support from Back Up
Use this form to let us know who needs support and how we can help
Referral Details
Who are you referring?
Myself - I have a spinal cord injury
Myself - I have a family member with a spinal cord injury
Someone else with a spinal cord injury
A family member of someone with a spinal cord injury
What is your role?
Please select...
I am a healthcare professional
I am a case manager
I am a spinal cord injury centre staff member
I am a family member or friend
Connect Service
I would like to talk to someone who understands with a one-off chat
Which service are you interested in?
This is the team that will be in touch first. If you are not sure, please select 'getting started' and our Outreach and Engagement team will be in touch.
Which service are you interested in?
This is the team that will be in touch first. If you are not sure, please select 'getting started' and our Outreach and Engagement team will be in touch.
Which service are they interested in?
This is the team that will be in touch first. If you are not sure, please select 'getting started' and our Outreach and Engagement team will be in touch.
Which service are they interested in?
This is the team that will be in touch first. If you are not sure, please select 'getting started' and our Outreach and Engagement team will be in touch.
Programme ID Myself SCI
Programme ID Myself Family
Programme ID Third Party SCI
Programme ID Third Party Family
FA Choice ID Myself SCI
FA Choice ID Myself Family
FA Choice ID Third Party SCI
FA Choice ID Third Party Family
Are you interested in other Back Up programmes?
Yes
No
Are they interested in other Back Up programmes?
Yes
No
Please select all that apply
Support for children and young people
Online 'What Next?' course to help you understand and adjust to life after spinal cord injury
Residential courses
Join our fortnightly Back Up Lounge to connect with others online
Support for family, friends and loved ones
Talk to someone who understands - regular support (up to 10 sessions)
Wheelchair skills
Getting started (understanding more about spinal cord injury)
Getting back to work, volunteering or studying
Information and advice for managing your energy costs alongside spinal cord injury
Honeypot Field
About you
Your Details
Organisation
If your organisation is not listed, please type it in manually.
Organisation Type
Organisation ID
Title
First Name
Surname
Preferred Name/Known As
Date of Birth
Age
Email
Email
Mobile Number
Mobile Number
Home Address
House Name/Number and Street
Please start typing your address and select it when found.
Town/City
Postcode
Organisation Address
Building Name/Number and Street
Please start typing your address and select it when found.
Town/City
Postcode
What is your relationship to the person with a spinal cord injury?
Please select...
Partner/Spouse
Parent
Child
Adult Child
Sibling
Friend
Other
Are you their next of kin?
Yes
No
Communication Preferences
We will try and contact you to support you using your preferred method, however, this may not always be possible.
Method
Marketing Preferences
Would you like to be kept up to date on Back Up's latest news by email?
Yes please
No thank you
About the person you are referring
Someone with SCI
Their details
Please ensure you have their permission to disclose this information. We appreciate that you may not know all of the details about the person you are referring, so please complete as much as possible and leave the rest blank. We may contact you if we need any further information.
Title
First Name
Surname
Preferred Name/Known As
Date of Birth
Age
Email
Mobile Number
Home Address
House Name/
Number
and Street
Please start typing their address and select it when found.
Town/City
Postcode
Are you their parent/guardian?
Yes
No
By submitting this form you are confirning your consent for us to provide support to your child.
About the person you are referring
Referring Family Member
Their details
Please ensure you have their permission to disclose this information. We appreciate that you may not know all of the details about the person you are referring, so please complete as much as possible and leave the rest blank. We may contact you if we need any further information.
Title
First Name
Surname
Preferred Name/Known As
Date of Birth
Age
Email
Mobile Number
Home Address
House Name/Number and Street
Please start typing their address and select it when found.
Town/City
Postcode
Are you their parent/guardian?
Yes
No
By submitting this form you are confirning your consent for us to provide support to your child.
What is their relationship to the person with a spinal cord injury?
Please select...
Partner/Spouse
Parent
Child
Adult Child
Sibling
Friend
Other
Are they their next of kin?
Yes
No
Parental Consent
As you are under 18, we need your parent's consent before we can support you. Please add their details below and we will send them a simple form to complete.
First Name
Last Name
Email
As the person you are referring is under 18 and you are not their parent/guardian, we need their parent's consent before we can support them. Please add their details below and we will send them a simple form to complete.
First Name
Last Name
Email
Page 6
Back Up Connect
From the following list of mobility levels please select the one that best describes you and we’ll connect you to someone with a similar level of injury.
Speak to someone who understands living with an incomplete injury
Speak to someone who understands living with a complete injury
Speak to someone who understands living with high-level tetraplegia
Age
You can talk to a Connector about any number of topics related to life with spinal cord injury.
Please select any of the following that you may wish to speak about so that the Connectors can be aware prior to your conversation. Please be aware they are not medical professionals.
Please select the topic you would like to discuss with your Connector:
Bladder management
Bowel management
Managing care
Managing pain
Getting out and about
Travel and holidays
An introduction to Back Up Trust
I’m looking for legal advice
Other topic
Other topic details
Back Up Connect is a service that is delivered by trained ‘Connectors’. We will do our best to connect you with a suitable Connector, subject to availability, however this may take a few days. Please be aware that this service is not intended for emergencies or urgent issues.
Communication Channel Preference
Please select...
Phone Call
Email
If your query is complex we recommend you choose a telephone call because the email option will consist of a single reply from the Connector, with no option to reply to them.
About the spinal cord injury
Who is the person with the Spinal Cord Injury?
First Name
Surname
Date of Birth
Hospital or Rehabilitation Details
Are you currently in spinal rehabilitation?
Yes
No - previously received rehabilitation
I did not receive any rehabiliation in a spinal cord injury centre or hospital
Where are you receiving rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Where did you receive rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Is your family member currently undergoing rehabilitation?
Yes
No - previously received rehabilitation
They did not receive any rehabilitation in a spinal cord injury centre or hospital
Where is your family member receiving rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Where did your family member receive rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Is the person you are referring currently undergoing rehabilitation?
Yes
No - previously received rehabilitation
They did not receive any rehabilitation in a spinal cord injury centre or hospital
Where are they receiving rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Where did they receive rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Is the person you are referring's family member currently undergoing rehabilitation?
Yes
No - previously received rehabilitation
They did not receive any rehabilitation in a spinal cord injury centre or hospital
Where are they receiving rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Where did they receive rehabilitation?
In a Spinal Cord Injury Centre
Hospital
Spinal Cord Injury Centre
SCIC Account ID
Hospital
Please select from the list. If the hospital is not already in the list, you can add it manually.
Hospital Account ID
Date of Discharge
Do you know the details of the injury?
Yes
No
Injury Details
Date of Injury
Year of Injury
You only need to complete this if you don't know the exact date.
Level of Injury
C1
C2
C3
C4
C5
C6
C7
C8
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
S1
S2
S3
S4
Para
Tetra
Cauda Equina Syndrome (CES)
Please select all that apply.
Injury Type
Is a ventilator required?
Yes
No
Sometimes
Cause of Injury
Further details about the cause of injury
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information