MSIreland Casework Service - Expression of Interest

The MSIreland Casework Service is a support service wherein the Community Worker responds to contact made by a Person with MS (PwMS) and their families. At the time of diagnosis and at different points during a person’s MS journey, the Community Worker provides information and support. Community Workers can provide support around issues such as symptom management, social protection entitlements, medical card applications, employment, education, housing, the emotional & psychological challenges of living with MS and the impact on relationships. Where appropriate Community Workers also signpost and refer PwMS and their families to other healthcare professionals, other service providers or local voluntary branches.

How is my information managed?

This form will help us learn about you and what you would like to gain from the Casework Service. Your information is input directly into MS Ireland's SalesForce database system and is only available to the Casework Service.

However, to avoid unnecessary duplication within our database, your name, email and date of birth only will be visible to all MS Ireland staff.

Please enter the following details for the Person with MS who is interested in availing of this service:

Your First Name

Your Surname

Preferred Phone

Mobile PhoneLandline

Landline

Mobile Phone

Email Address
Reminder: This should be the email address for the Person with MS interested in availing of this service

Date Of Birth eg. dd/mm/yyyy

Please state your own Full Name and Relationship (if you are a family member) or Professional Role (if Carer or Health Care Professional)

Your own name role and email address

Which County do you live in?

Do you live in Tipperary North or Tipperary South?
If possible, please also provide your EIRCODE
* We ask so that we know which of our Community Workers to assign your case to...

Date Of Diagnosis eg. dd/mm/yyyy

Briefly outline your reason for contacting the MSIreland Case Work Service

GDPR and Consent - In order for the MSIreland Casework Service to comply with current General Data Protection Regulations (GDPR) we are required to obtain your formal consent to gather and use information about you. Under this regulation MS Ireland must adhere to the following:

1. Valid consent must be explicit for the data collected and the purposes the data is used for

2. The consent does not imply consent forever

3. The data must only be used for the purpose it was initially intended for and no other

Following your expression of interest a member of our team will be in touch with you regarding completion of a referral.

*Consent is required to submit this Expression of Interest form. Without your consent, there is no way for MSIreland to deliver its casework service on your behalf.*

I consent to the MS Ireland Casework Service creating and updating a file with my data

Yes - I consent to the GDPR policy outlined aboveYes - I am a healthcare professional/MSIreland staff member referring a person who has given their verbal consent for me to complete this form on their behalf

Thank you for completing this form which will be reviewed shortly by the MSIreland Casework Service

Contact Information