Connection Scheme Form

Contact Information

Country
Email*
Confirm Email*
Phone
Preferred Method of Contact with Connections - Please choose ONE (If you are outside of the UK we would recommend you use email for cost effective communication)*
  • Email
  • Telephone
  • Letter

Connection Details

Please fill out the below details in order for us to find connections in our scheme. 

Your Gender*
  • Female
  • Male
  • N/A
  • Other
  • Unknown

Tell us about some of the outcomes that have been experienced post encephalitis

Behavioural Consequences
  • Personality Change
  • Aggression
  • Disinhibition
  • Confabulation
  • Self-neglect
Cognitive Consequences
  • Memory Problems
  • Poor Attention and Concentration
  • Slow speed of thinking
  • Executive function difficulties (planning, problem solving, organisation, flexibility)
  • Lack of insight/awareness
  • Language and communication problems
  • Learning difficulties
Emotional Consequences
  • Emotional liability (difficulty controlling emotions)
  • Frustration and Anger
  • Perception of emotions of self & others
  • Anxiety
  • Depression
  • Changes in self-concept & self esteem
  • Loss of confidence
Senses Consequences
  • Visual
  • Auditory
  • Touch
  • Smell
  • Taste
Physical Consequences
  • Paralysis
  • Weakness
  • Balance/Ataxia/Coordination
  • Dyspraxia (difficulty with purposeful movement)
  • Dysarthria (difficulty in pronunciation)
  • Dysgraphia (difficulty in writing)
  • Dysphagia (difficulty in swallowing)
  • Bowel Incontinence
  • Bladder Incontinence
Psychiatric Consequences
  • Phobias
  • Paranoia
  • Delusions
  • Obsessions
Homeostasis Consequences
  • Overeating/ Weight Gain
  • Loss of Appetite / Weight Loss
  • Body Temperature Control
Other Consequences
  • Epilepsy
  • Fatigue
  • Headache
  • Sleep Problems
  • Sexual Problems
  • Other Problems
Difficulties Experienced Post Diagnosis
  • Financial
  • Employment
  • Educational
  • Relationships
  • Medical
  • Socio/Economic
Membership*
  • By submitting this form you agree to become a Member of The Society and to the terms and conditions of this scheme. [Please Note: Membership is Free]

It is important to us to be able to engage with you and keep you up to date with the latest news about encephalitis and our work. This might include information about fundraising and research or other aspects of our work that help us meet our primary aim of improving the quality of all lives affected by this often-devastating condition. Please tell us how you prefer to hear from us and the different ways that we can keep in touch with you.

Consented to be contacted via*
  • Email
  • Post
  • Telephone
  • Does not consent
  • Newsletter - Email Only
  • Newsletter - Post only
  • Social Media
  • Text Message

By completing and submitting this form you are confirming you have understood the terms and conditions of and are agreeing to be part of the Scheme which involves the sharing of your information with others within the scheme. By submitting this form you are also agreeing to the Encephalitis Society holding the information contained within on our database, this information will be kept in accordance with the Data Protection Act 1998. You have the right at any time to request your information be deleted from our database or to be removed from the scheme, please contact the Society directly. The Encephalitis Society cannot be held responsible for the content of interaction between Connections (others signed up to this scheme). The Society maintains the right to deny or restrict access to this scheme as deemed necessary in particular due to a breach of our communication guidelines by an individual.

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