Join Cork Stroke Support

Who can make a referral?

  • Yourself
  • A health professional on your behalf
  • A family relative with your consent

What happens when you make a referral?

Stroke survivors (or relatives) referred to the service, will receive a phone call from a health professional and will be offered an individual consultation in the Cork Stroke Support Centre.

Explore our services for more information about what we do

To make a referral, complete the form below

Alternatively, download this document (Word) and return it to

Alternatively, you can call us at the office and we will help you.

    Stroke Survivor Information

    Emergency Contact


    Medical History

    Details of Stroke

    Other health issues of significance

    Other community services engaged or referred to

    Arrangements for medical follow-up

    Referral Information

    Self Referral

    Referral made by family member with persons consent

    Referral made by Health Professional

    Client consents to CSS application

    Client consents to personal information held on file

    Information on this form will be treated, as strictly confidential, in accordance with the provisions of the General Data Protection Regulations 2018. No personal or medical information will be disclosed to a third party on an individual identifiable basis without your consent. On receipt of this referral, CSS will provide a follow-up phonecall and offer an appointment in the Cork Stroke Support Centre for a consultation with a health professional. This is required to access CSS peer support activities.