Pae Ora Referral Form - Purapura Whetu

Pae Ora - Healthy Lifestyles

Kaupapa

Pae Ora Ki Waitaha is a healthy lifestyles promotion service developed in consultation with Kaupapa Māori and Pasifika providers to support priority populations to access holistic health improvement programmes.

Pae Ora is available to all people meeting the criteria, including those with disabilities or mental illness, however, please note that the intention of Pae Ora is to meet the needs of those seeking support for physical health conditions.

Pae Ora Referral - Draft

Step 1 of 3

Pae Ora is available to individuals who meet one or more of the following criteria: - Under 65 years old, have a lifestyle related physical health condition and one of the following (please select any that apply):
- Māori
- Pasifika
- Culturally and linguistically diverse (CALD)
- Remote rural
- Tamariki referred via the B4 Schools programme, as per the B4 school check guidelines
- LGBTQIA+ community
Date*
DD dash MM dash YYYY
Referral type:*
Referrer Details
Referrers Name
First Last
Referrer Organisation
Referrer's Phone
Referrer's Email
Whanau Members Details
Whanau Member (Referrer's) name
First Last
Relationship to client
Phone
Whānau Member (Referrer's) Email

GP Details
GP Name
Practice Name
Phone
Address
Street Address Address Line 2 City ZIP / Postal Code
Email
Referral Details
Other programmes/services currently involved in:
Please use this space to provide a reason for the referral:*
Upload any relevant documentation:
Drop files here or

Max. file size: 256 MB.
Including treatment/discharge summary
CAPTCHA