FORMS Spinal Support NZ Membership Form 1. PERSONAL DETAILSI would like to * Required Become a new member Update my details Although filling in your address and phone number may not be required for some options, we encourage you to complete these details. Your local Coordinator can then inform you about any social events or Gatherings organised in your area.Name * Required First Last Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Gender * Required Male Female Other Marital Status: * Required Single Married Date of Birth * Required DD slash MM slash YYYY Name of Partner/Contact: Dependents * Required 2. CONTACT DETAILSHomeWorkMobileEmail * Required 3. MEDICAL DETAILSIs your injury due to an accident? * Required Yes No Level of Injury: * Required Complete / Incomplete Date of Accident: * Required DD dash MM dash YYYY Please briefly describe how the accident occurred: * RequiredIs your injury due to medical reasons? Yes No Level of Injury: * Required Complete / Incomplete Date of Condition: * Required DD dash MM dash YYYY Please briefly describe medical condition: * Required4. OTHER (Optional)Nationality: Citizenship: Religion: Do you smoke? Yes No Do you drink? Yes No Occupation(s): Hobbies / Interests: Describe your Personality: (check which ones you feel apply to you) Friendly Outgoing Easygoing Shy Reserved Positive Other (please specify) Please specify your Personality Describe your attitude towards life: (check which ones you feel apply to you) Conservative Middle of the Road Broadminded Other (please specify) Please specify your attitude towards life 5. BUDDY Would you like a Buddy? * Required Yes No Is gender important? * Required Yes No Is age important? * Required Yes No ACC/MOH issues relevant? * Required Yes No Is nationality important? * Required Yes No Religion? * Required Yes No Further CommentsI would like to receive a copy of the information I have submitted Yes No Δ The Supporter Newsletter Form Note: More questions will appear as you fill in the form. 1. I would like to Receive the Newsletter Update my details 2. I would like to Receive a paper copy of The Supporter Newsletter Receive The Supporter Newsletter by email Receive The Supporter Newsletter by email and stop receiving my paper copy 3. I would like to I would like to update my address Receive the newsletter by email and stop my paper copy Although filling in your address and phone number may not be required for some options, we encourage you to complete these details. Your local Coordinator can then inform you about any social events or Gatherings organised in your area.Name for Email List * Required First Last Email Address for Email List * Required Enter Email Confirm Email Contact Email for receiving papercopy * Required Enter Email Confirm Email Name For Posting the Newsletter * Required First Last Phone Number (with area code please) * Required AddressAddress * RequiredPlease stop the paper copy being sent to my address at:Name on the current papercopy First Last Please stop the paper copy being sent to my address at:Email for contacting regarding changing postal address * Required Enter Email Confirm Email My previous postal addressMy new postal addressMy Phone Number (with area code please) * Required Further commentsI would like to receive a copy of the information I have submitted Yes No Δ Peer Support Interaction "*" indicates required fields Peer Supporter * Required Name of Peer Supporter.Client Name * Required Name of Client being supported.Date of Interaction * Required DD slash MM slash YYYY Date peer support interaction occurred.Follow up date * Required DD slash MM slash YYYY The next appointment date occurs.Duration (Minutes) * Required The amount of time taken for the interaction (in minutes).Travel (Km) Mileage travelled in km, if any.Interaction Type * RequiredOne-on-one interactionEmailGroup discussionFormal MeetingCommunication via social mediaCommunication via direct messagingPhone callVideo callUpdateOtherHow the client was contacted.Interaction Location * RequiredBedside – patient in bedBedspace – patient seatedWard public spaceWard treatment areaOutdoors at Spinal UnitPeer support officePerson’s homeCommunity settingRehab gymOtherWhere the interaction occured.Family Present * RequiredNoYesFamily onlyProvider/Clinician onlyWere family present at the interaction?Topics Covered * RequiredGeneral chatApplication supportBedrestBladderBowelsDischargeEquipmentFatigueFunder processesFutureGoal SettingInjury mechanismMedical issuesModificationsMood/Mental health informationOuting/Community integrationPainPre SCIRehabilitation processesSex/RelationshipsSpasmsTeaching Problem SolvingTransfersTransitional rehabVehicleVocational issuesW/C skillsWounds and pressure areasOther Topics covered during interaction.Notes (optional)General notes about the interaction. 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