Purapura Whetū Single Point of Entry Referral Referral Type* Self Whānau/friend/other Agency/Professional Haputanga Wānanga I am registering for* Wahakura Wānanga Ipu Whenua and Waka Pito Navigating Newborns Midwifery Sessions Select all that apply Upcoming Wahakura Wānanga Dates - Limited Spaces Available:* Saturday 29th August: 10am-5:30pm Saturday 26th September: 10am-5:30pm Saturday 31st october: 10am-5:30pm Saturday 28th November: 10am-5:30pm Select all that apply Upcoming Ipu Whenua and Waka Pito Dates - Limited Spaces Available:* Thursday 17th September, 5:30pm - 8pm Wednesday 18th November, 5:30pm - 8pm Tuesday 20th October, 9am - 11am Select all that apply Upcoming Navigating Newborns Dates - Limited Spaces Available:* 10th September: 5pm-8:00pm 14th October: 5pm-8:00pm 18th November: 5pm-8:00pm Select all that apply Upcoming Midwifery Session Dates - Limited Spaces Available:* 17th September: 5pm-8:00pm 15th October: 5pm-8:00pm 12th November: 5pm-8:00pm Select all that apply Legal name:* First Last Preferred name: First Last Ethnicity*Date of Birth* Day Month Year Expected due date of your pepi* Day Month Year NHI (if known)Phone*Email:* Address* Street Address City Do you have an allergies or food intolerances?*Is there anything we as facilitators need to be aware of regarding your pregnancy or personal hauora?*Are you interested in learning more about the services Te oriori and Pūmotomoto provide? **YesNoHow did you hear about Haputanga Wānanga?* Social Media Whānau and/or friends Billboard advertising Professionals e.g social worker, support worker, NGO organisation GP Word of mouth Other If other, please detail how you heard about our Haputanga WānangaI would prefer to be seen by a kaimahi who is a Tane (Male) Wahine (Female) No preference The tangata whaiora would prefer to be seen by a kaimahi who is a Tane (Male) Wahine (Female) No preference My Whānau member would prefer to be seen by a kaimahi who is a Tane (Male) Wahine (Female) No preference I would prefer to be seen On site - in an allocated therapy space Out in the community - settings and venues to be discussed with support worker At home No preference The tangata whaiora would prefer to be seen On site - in an allocated therapy space Out in the community - settings and venues to be discussed with support worker At home No preference My whānau member would prefer to be seen On site - in an allocated therapy space Out in the community - settings and venues to be discussed with support worker At home No preference Consent* Information: I agree that my information may be shared with other staff of Purapura Whetū for the purpose of ensuring I am referred to, and supported by, the most appropriate services, therapy and group programmes within Purapura Whetū. Community Access Pathway Consent* If you are referred to Te Kākano Hauora for support, or they are identified as the most suitable service for you, you consent to your information being shared and processed through the community access pathway Consent* I confirm that I, or the person named in this referral, consent to this referral being made. If the person is under 16 years of age, consent has been obtained from their parent or legal guardian. Is the person being referred 16 years of age or older?* Yes No Parent/Guardian DetailsParent/Guardian Name:* First Last Parent/Guardian Phone Number:*Parent/Guardian Email* Address* Street Address City Referrer DetailsName* First Last Relationship to person being referred*Agency/organisation*Agency AddressContact Phone Number*Referrer Email* Client/Whaiora DetailsLegal name:* First Last Preferred name: First Last Date of Birth* Day Month Year NHI (if known)Gender*PronounsShe/her, he/him, they,themEthnicity*Iwi (if applicable)Phone*Email* Address* Street Address City GP DetailsEnrolled with GPUnsureNoyesGP NamePractice NamePhoneEmailEmergency ContactName*Relationship*AddressPhone*EmailService RequestDo you know what service you are seeking support from?NoYesIf yes, please specifyTe Huinga Kōtuku - Gambling & gaming harm reduction supportTe Waharoa - Mental health support for all agesTe Piringatahi - Rangatahi and AOD supportTe Oriori - support for parents with tamariki aged 5-12Pūmotomoto - Support for Parents navigating pregnancy and first five years of your child's lifeTe Kauae - Elder Abuse supportTe Kākano Hauora - Mental health support for whaiora with a diagnosisWhānau ora KaitūwhanaWould kind of support would you like?Individual Therapy SupportGroup Programme Support - provided by Te Waharoa, Te oriori and PūmotomotoBoth Individual and Group SupportHow can we support you or the person you are referring? How would this improve yours/their wellbeing?*(Please include names and DOBs if referring whānau)How did you hear about Purapura Whetū?* Social Media Whānau and/or friends Billboard advertising Professionals e.g social worker, support worker, NGO organisation GP Word of mouth Other If other, please provide details*Additional Referral InformationPlease fill out the following fields with as much detail as possible, so we can provide the best support. Mental health diagnosis:NoYesIf yes, please specifyAre any of these areas affecting your wellbeing now (tick all that apply) Alcohol & Drugs Gambling and Gaming Mental Health Grief and Loss Experiencing or at risk of abuse (financial, elderly, physical, sexual) Which areas are affecting you the most? Gambling Gaming Screen/device/online addiction Select all that applyAre you or the person you are referring: Smokefree Not Smokefree and not wanting support to quit Not Smokefree, but wanting support to quit Please specify any co-existing conditionsCo-existing conditions means any other health, mental health, disability, addiction, or wellbeing concerns that may affect your support needs. Please include anything important, even if it has not been formally diagnosed.Current Supports:Are you currently or have you previously been engaged with any services within Purapura WhetūYesNoIf yes, please provide details:*Strengths:What are your strengths, supports or sources of strength (whānau, culture, skills, interests)*What are your whānau members strengths, supports or sources of strength (whānau, culture, skills, interests)*What is the whaiora you are referring strengths, supports or sources of strength (whānau, culture, skills, interests)*Risks / ConcernsAre there any risks or concerns we should be aware of?*YesNoIf yes, please provide details:Do you or the person you are referring have any current or previous engagement with Oranga Tamariki that you would like to share to help us support you better?YesNoI would prefer to talk about this later/not at this timeAny additional comments:Triage and Communication Response Times* I understand that once this referral has been received, it will be reviewed as part of the triage process. I acknowledge that it may take up to 14 days for a kaimahi to contact me. If you do not receive an acknowledgement email after submitting a referral, within 72 hours please email us at spoe@pw.maori.nz so we can ensure we have received your submission. Allergies / Dietary Requirements* I understand that catering arrangements may differ between group programmes. Te Waharoa will cater for food allergies and dietary requirements during group programmes. Te Oriori and Pūmotomoto will do their best to provide kai, however whānau may need to provide their own kai where specific allergies or dietary needs apply. Photography and Videography Consent: I understand and agree that any photographs, videos or other images taken of participants during activities associated with Purapura Whetū may be used for promotional purposes of similar activities, including material on websites, social media, and other advertising.YesNoPlease upload any relevant files Drop files here or Select files Max. file size: 256 MB.
