WHĀNAU ORA ENROLMENT FORM
KAUPAPA
Tahia Te Marae is about whānau/hapū needs and aspirations being at the centre of our services. We work with, and advocate for whānau/hapū when needed, so they are empowered to reach their goals & aspirations. Together, we are building whānau/hapū capability and trusting relationships between service providers, organisations and whānau/hapū.

WHĀNAU KEY CONTACT (Must be 18 years or over)

WHĀNAU ADDRESS (All whānau named live at this address)

Fields are required

NGA WHĀNAU

IWI / HAPŪ / MARAE AFFILIATIONS

(Identify tamariki/rangatahi under the affiliations of their parents)

REFERRAL AGENCY INFORMATION

OTHER SERVICES INVOLVED WITH WHĀNAU

Agency Servcies Provided Contact Number

INFORMED CONSENT AND SERVICE AGREEMENT (Please tick each statement as agreed to)

1 We have been informed of our rights under the Code of Health and Disability Services Consumers’ Rights (the Code) and we understand these rights.
2 We have been informed of Huria Trust’s complaints process and are aware that we can always discuss any concerns we have with kaihono or Huria Trust Chief Executive Officer.
3 We are aware that at any time the whānau (through our key contact person) or Huria Trust may cancel any part of or all of this agreement.
4 We consent to Huria Trust seeking and sharing information about our whānau to/from other health agencies we are engaged with, necessary to providing a quality service to us all as a whānau. We would like to be advised of this prior.
5 We understand that our information may be shared with a mandated government agency should there be serious and imminent threat to public health or public safety or to someone’s life or health.
6 We agree that Huria Trust may disclose our whānau information (ensuring no identification of any of our whānau members) to a third party for reporting, monitoring and/or auditing purposes.
7 We are aware that at any time we may request access and make corrections to our whānau information held by Huria Trust.
8
We understand that:
  • We shall take responsibility to contact kaihono should we be unable to keep appointment times arranged.
  • If we choose another service provider, our record(s) with Huria Trust will be closed and records may be forwarded at our request.
  • Storage and recording of our information will be safeguarded using no less than two secure methods. For example: a locked filing system (manual files) and/or an electronic client management system.


9 Under these circumstances we consent to the service.