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Referral to Complex Chronic Illness Support
Thank you for your interest in our services. We support people living with the following conditions, and the people that support them.
* ME/CFS - Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
* Fibromyalgia
* Post-Viral Fatigue / Syndrome
* Dysautonomia - we support postural orthostatic tachycardia syndrome (POTS), Orthostatic intolerance (OI) and Neurally Mediated Hypertension (NMH)
* Long-COVID
In order to ensure that we get the right team to support you, please complete this application.
If you are a Family member or Friend requiring support for yourself. Please use this form instead.
Supporters Referral
Consent to Collect information
I authorise the collection of information that may be relevant to my illness.
I understand that in the collection, use and storage of this information, Complex Chronic Illness Support will at all times comply with the Privacy Act 2020 and the Health Information Privacy Code 2020.
I understand that I have the right to access and ask for the correction of any information, Complex Chronic Illness Support may hold about me.
We may use and disclose your personal information for purposes directly related to your care/support and in ways you would reasonably expect for your ongoing care, or in accordance with the Privacy Code. This may include, but is not limited to, the transfer of relevant personal information to your nominated GP, to another health service or hospital, or to a specialist for a referral. This will be done with your consent
We may disclose relevant information with relevant agencies if we feel there’s a serious threat or risk to yourself or another person's safety, this will be done in accordance with the Privacy Code 2020.
Consent received via
*
The collection of information is from you on this form and future forms/meetings with CCI Support, unless we have your permission we do not approach other agencies for information.
Consent MUST be received before this form can be completed.
Yes, I agree to the collection of my relevant information
Consent to collect received verbally
Who is completing this form?
Myself
A Support Person
Name
*
First name
Last name
Address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Email address
*
Phone
*
Preferred contact method
*
Email
Text
Letter
Phone
Facebook
Slack
Cell
Date of Birth
*
We do need to know your age for contract and funding purposes. And also so we can provide you with the most appropriate services. Thanks
Gender
*
If you have selected other, please confirm below what you identify with. Thanks
This is required for funding purposes
Female
Male
Other
They/Them
Unknown
Ethnicity
*
Asian
Indian
Maori
NZ European
Other
Pacific Islander
Would rather not say
How did you hear about CCIS?
Counsellor
Doctor
Member of another ME/CFS group
Newspaper
Other
Self/Family Referral
Social Media
Website
Have you been diagnosed with any of the following?
*
Fibromyalgia
Long COVID
ME/CFS - Chronic Fatigue Syndrome
Not yet Diagnosed
Orthostatic Intolerance
Other
Post Viral Syndrome
POTS - Postural Orthostatic Tachycardia Syndrome
If so, who made the diagnosis for you?
Who is your current Health Professional?
Are you happy with your GPs level of understanding of your complex chronic illness?
Yes
No
Do you have any other health related conditions eg. mental illness, disability, or other medical conditions?
How long have you been feeling unwell, ME/CFS or the condition you are needing support with.?
Where are you at right now?
This won't affect care or support. This just gives us an indication of the type of support you require.
a. No symptoms with exercise. Normal overall activity. Able to work or do house/home work full time with no difficulty.
b. No symptoms at rest. Mild symptoms with physical activity. Normal overall activity level. Able to work full time without difficulty.
c. Mild symptoms at rest. Symptoms worsened by exertion. Minimal activity restriction needed for activities requiring exertion only. Able to work full time with difficulty in jobs requiring exertion.
d. Able to work/do housework full time with difficulty. Needs to rest in day.
e. Unable to work full time in jobs requiring physical labour (including just standing), but able to work full time in light activity (sitting) if hours are flexible.
f. Unable to perform strenuous duties, but able to perform light duty or deskwork 4 - 5 hours a day, but requires rest periods. Has to rest/sleep 1-2 hours daily.
g. Able to go out once or twice a week. Unable to perform strenuous duties. Able to work sitting down at home 3-4 hours a day, but requires rest periods.
h. Usually confined to house. Unable to perform any strenuous tasks. Able to perform deskwork 2-3 hours a day, but requires rest periods.
i. Unable to leave house except rarely. Confined to bed most of day. Unable to concentrate for more than 1 hour a day.
j. Bed ridden the majority of the time. No travel outside of the house. Marked cognitive symptoms preventing concentration.
k. Severe symptoms on a continuous basis. Bed ridden constantly, unable to care for self.
What is your Current Occupation?
How are you currently supporting yourself?
Being Supported by another person
On a different benefit
On a Job Seeker Benefit
On Supported Living Payments
Other means of supporting myself
Receiving a Disability Allowance
Receiving Temporary Additional Support
Studying
Working Full Time
Working Part Time
What is your Living Situation
Homeless
I'd rather not say
Living in a flatting situation
Living in own home
Living with Friends/Family
Retirement Village/Home
What support do you feel you need?
How has COVID affected you?
These questions are not mandatory, the data is collected so that we can provide information on how COVID has affected our community, we are using it to advocate for extra support and funding within the COVID narrative, for ALL people with ME/CFS, including those with long COVID.
Have you received the COVID vaccine?
This is only asked, so we can provide you with the most suitable situation to meet with you. We work with both Vaccinated and Non Vaccinated clients and families!
No
Yes
Did you get ME/CFS symptomology FROM the vaccine?
No
Yes
Have you had an ME/CFS symptom relapse post vaccination?
No
Yes
If you tested positive for COVID? When?
Did you get a ME/CFS relapse post COVID virus?
No
Yes
Symptomology you currently have
Fatigue and Pain
Do you experience fatigue?
*
Always
Sometimes
Rarely
How soon/long after an activity do you feel fatigue or a worsening of your symptoms? (eg fatigue, muscle pain)
*
Straight away
12 hours
24 hours
I dont experience delayed fatigue
Does anything reduce the fatigue?
*
Do you have any pain?
*
Always
Sometimes
Rarely
What type of pain?
*
eg joint pain, headaches??
What areas does the pain effect?
What medication/treatment works for you or what have you tried?
Are you still able to do physical activity?
*
Yes
No
Sleeping
Do you have difficulty getting to sleep?
*
Always
Sometimes
Rarely
Never
Do you wake feeling refreshed?
Always
Sometimes
Rarely
How many hours sleep a night do you typically get?
*
Do you sleep through the night without waking?
*
Always
Sometimes
Rarely
Can you go back to sleep if you wake?
*
Always
Sometimes
Rarely
Do you nap during the day?
*
Always
Sometimes
Rarely
Never
Is there anything that helps to improve your sleep?
Cognitive
Do you have difficulty concentrating?
*
Always
Sometimes
Rarely
Do you experience confusion or Brain Fog?
*
Always
Sometimes
Never
Do you have difficulty with word recall & memory?
*
Always
Sometimes
Never
Are you sensitive to noise?
*
Do you have to come away from things?
Always
Sometimes
Never
Do you find the lights/sun etc too bright?
*
Always
Sometimes
Never
General Questions
Do you struggle to carry out the tasks of daily living or participate in pre-illness activities?
Can be Occupational, Educational. Social or in your personal life.
Always
Sometimes
Never
Have you developed any food sensitivities?
*
Yes
No
Do you feel like you're about to get the flu, but do not?
*
Always
Sometimes
Never
What is your Blood Pressure like?
If you know
Low
Normal range
High
Do you faint or feel light-headed or dizzy at times?
*
Always
Sometimes
Never
Do you experience gut issues?
*
Yes
No
Sometimes
If so, how do these issues present for you?
Do you have Nausea?
*
Always
Sometimes
Never
Do you experience temperature fluctuations?
*
Do you have difficulty regulating your temperature?
Always
Sometimes
Rarely
Do you have problems with transport?
*
Do you have your own? Rely on health shuttles? Have no access to transport or not well enough to leave house?
Has your mental health suffered because of your illness?
*
How is your life affected by your condition?
*
Do you have any additional information which will be helpful for us to know about, in your current situation?
Thank you for completing this referral form. We will assess your information to make sure we are the right organisation to support your health needs. A Health & Wellness Facilitators will be in contact with you, as soon as they are able.
Kind Regards,
The Team at CCIS
Please check the highlighted fields
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