1. Support Person Referral

Requiring Support from Complex Chronic Illness Support

At CCIS, we recognise the important role that family, partners, friends and carers play in supporting someone with a complex chronic illness. The work is often stressul and demanding, and can take its toll on social, emotional and physical wellbeing of those providing support.

That is why we believe that supporting you is vital for the health and happiness of both.

To help us assess your needs, please provide the information requested below.

Consent to Collect information

I authorise the collection of information that may be relevant to my support.

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.

Consent received via *

Consent MUST be received before this form can be completed.

Name *

First name

Last name

Address *

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Phone *

If you have no phone please just put 1234567

Email address *

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, so that we can address you appropriately. Thanks

Name of Person you are supporting

What is the age of this person?

Relationship to you?

How long have they been unwell?

Does the person you support have one of the illnesses that is supported by CCIS? Please select their illnesses below.

ME/CFS - Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Fibromyalgia

Post Viral Fatigue / Syndrome

Long COVID

Dysautonomia - a term for a group of diseases that include postural orthostatic tachycardia syndrome (POTS)

Has a Health Professional diagnosed their condition? *

Are they a member of CCIS?

How has your life been affected by their condition? *

Do you have any ongoing health-related issues?

What support do you feel you need? *

Would you be interested in attending a Support Persons Workshop?

How did you hear about CCIS?

Do you have any additional information which will be helpful for us to know about your current situation?

Thank you for completing this 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 of CCI Support.

43 Welcome Bay Rd, Welcome Bay, Tauranga 3112
P: 022 658 0251 or 0800 224 7871
E: info@ccisupport.org.nz
W: www.ccisupport.org.nz