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FCSA's Center of Excellence Program Application
Welcome to the Fibromyalgia Care Society of America's Virtual Support Services Program- The Center of Excellence! Applications are open to all states and are on a rolling basis.
We are so excited to learn more about you as we begin your on-boarding process. The following application will help us to better meet your needs. All information shared is confidential.
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* Indicates required question
Full Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Full Mailing Address
*
Your answer
City State and Zipcode
Your answer
Is it OK for Program Staff to contact you via the phone (including text and voicemails) and/or email?
*
Yes
No
If you answered "NO" to the above question, please share how you prefer to be contacted
Your answer
Emergency Contact Name
*
Your answer
Emergency Contact Relationship
*
Your answer
Emergency Contact Phone Number
*
Your answer
Emergency Contact Email Address
*
Your answer
Is it OK to contact your Emergency Contact in case you become disengaged with the program in the future?
*
Yes
No
The Center of Excellence Program is 100% Virtual. Do you have reliable internet and full access to technology?
*
Yes
No
On a scale of 1-5, how confident do you feel using ZOOM?
*
Not confident at all, I will need help learning
1
2
3
4
5
Very Confident
On a scale of 1-5, how confident do you feel using email?
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Not confident at all, I will need help learning
1
2
3
4
5
Very Confident
Date of Birth
*
MM
/
DD
/
YYYY
Current Age
*
Your answer
To which gender identity do you most identify?
*
Woman
Man
Transgender Woman
Transgender Man
Gender Varient/Non-Conforming
Prefer not to answer
Other:
Preferred Pronouns
*
She/Her
He/His
They/Their
Prefer not to answer
Other:
Family Size - Annual Income
*
No Income
1 Person - Under $12,880
2 People - Under $17,420
3 People - Under $21,960
4 People - Under $26,500
5 People - Under $31,040
6 People - Under $35,580
7 People - Under $40,120
8 People - Under $44,660
Other:
At what age were you diagnosed with Fibromyalgia?
*
Your answer
Are you a veteran?
*
Yes
No
Have you been impacted by trauma? If so, what kind?
*
Your answer
Do you believe Fibromyalgia may have impacted your emotional well-being?
*
Yes
No
Maybe
Would you be interested in engaging in one on one therapy with the Center of Excellence program? (not mandatory)
*
Yes
No
Maybe
A variety of Empowerment Groups are offered by the Center of Excellence Program such as therapeutic, peer to peer and holistic coping groups. Are you willing to participate in at least one per week, if this was mandatory?
*
Yes
No
Check off the Case Management areas you believe you would need assistance with
*
Housing
Access to Food and/or Food Stamp Benefits (ie. SNAP)
Disability Benefits
Identification Documents (birth certificate, social secuirty card, ID, etc)
Health Insurance
Navigating the Medical System
Education (e.g. high school diploma, college, vocational training, etc)
Employment (e.g. referrals, resume, interview prep, learning how to apply, etc)
Connecting to a Community for Spiritual Wellness
Financial Support for Utilities and/or Rent
Legal Assistance
Other:
Required
One of the Center of Excellence's focus is Nutrition! Check off the related services you would be interested in participating in
*
E-Courses about different Diets
Facebook Group Community
Informational Webinars
Fresh Produce Delivery
Resource Guide
Accountability Partner(s)
Other:
Required
After you complete the Center of Excellence program, do you think you would be interested in becoming an "alumni" to offer peer to peer support?
*
Yes
No
Maybe
If enrolled in the Center of Excellence's upcoming cohort, when would you be available to begin?
*
As soon as possible
I need 30 days
I need 3 months
I need 6 months
Anything else you would like to share with us?
Your answer
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