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Referral/Registration Form
Client Details
Client name
*
First name
Last name
Cell phone
*
Other phone
Email address
*
Client address
*
Address line 1
Address line 2
Address line 3
Address line 4
Town/Suburb
City
Postcode/Zip
Gender multi-selection
Female
Male
I would rather not say
Other
Date of Birth
*
Age
*
NHI Number
*
Community Services Card Number
Ethnicity
*
New Zealand European
Māori
European
Pacific Islander
Middle Eastern
Asian
African
North American
South American
Australian
Don't know
Other Ethnicity
Spouse/carer/whānau name
*
Spouse/carer/whānau phone number
*
Spouse/carer/whānau email
Spouse/Carer Relationship to You
I would like to receive your newsletter
We triage your referral based on urgency, so please tell us why you are contacting us.
Reasons for joining MS & Parkinson's
Newly diagnosed - in the last 12 months
Education and support on how to manage my condition
Health and Wellbeing Assessment -1:1 assessment to discuss your health condition and how it is impacting your wellbeing, your home support needs, psychosocial support and referrals, education on living well with MS or PD, connection with others
Exercise Assessment - required before you join many of our exercise classes, provides an individual exercise programme, lifestyle advice, promotes exercise as medicine
Exercise classes and gym
Peer Support Groups and meeting others
Education and Workshops
Help to access community services or groups
Podiatrist
Total Mobility
Other
If you choose 'other', please tell us more about your reason for joining.
Referrer Details
Referrals
Self
Family member
Health professional
Other
Referrer name (if not self referral)
Relationship to client
Phone Number:
GP Name
*
Medical Centre
*
Medical centre phone number
Neurologist
Neurologist name
Date of Diagnosis
Diagnosis
*
Multiple Sclerosis
Relapsing Remitting MS (RRMS)
Primary Progressive MS (PPMS)
Secondary Progressive MS (SPMS)
Clinically Isolated Syndrome (CIS)
Parkinson's Disease
Parkinson's Disease with Dementia
Parkinsonism
Vascular Parkinsonism
Lewy Body Dementia (LBD)
Corticobasal Degeneration (CBD)
Multiple System Atrophy (MSA)
Progressive Supranuclear Palsy (PSP)
Unsure of diagnosis
No diagnosis
Consent:
Client/support person is aware of and agrees to the referral
*
Please note we are not an emergency service - if you have a health emergency, please phone your GP or 111 for an ambulance.
We triage your referral based on urgency, so please tell us why you are contacting us. As a free community service, we are experiencing increased demand for face-to-face appointments – we aim to offer a Fitness Assessment within four weeks, and a Health & Wellbeing Assessment within 12 weeks.
Some matters can be resolved over the phone by our duty worker, you are welcome to contact us on 03 366 2857 to see if they can help immediately, or if you need an appointment.
Form updated May 2024
Please check the highlighted fields
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