Referrals - Te Rūnanga o Ngā Maata Waka Incorporated

03 382 6628

Referrals

Accessing our services here at
Te Rūnanga o Ngā Maata Waka is simple.

*PLEASE NOTE – Driving Referrals are not currently being accepted

This referral form is to support whānau by connecting them with the right services, at the right time.
Individuals can self-refer by simply filling out the online form or calling 03 382 6628 for more information.

Referral Form

Accessing our services here at
Te Rūnanga o Ngā Maata Waka is simple.

This referral form is to support whānau by connecting them with the right services, at the right time.
Individuals can self-refer by simply filling out the online form or calling 03 382 6628 for more information.

Please complete all sections to ensure a smooth and safe process, and check for a confirmation message on submission before leaving the page.

Date of Referral:(Required)

Are you completing this referral for yourself or someone else?(Required)

Myself

Someone Else

Referrer Details

Referrer Name(Required)

First Last

Organisation (if applicable)

Referrer Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referrer Role/Position

Referrer Phone Number(Required)

Referrer Email(Required)

Relationship to the individual/whānau

Individual/Whānau Being Referred

Name(Required)

First Last

Preferred Name (if different)

Date of Birth(Required)

Gender(Required)

Male

Female

Takatāpui

Other

NHI

Ethnicity(Required)

Other (Please Specify)

Iwi Affiliation (if known)

Contact Number(Required)

Email(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Preferred method of contact

Interpreter needed?

Yes

If Yes, specify language

Services Requested

Tick one or more relevant areas:

Services(Required)

Other (Please Specify)

Hidden

Who is this referral for?(Required)

You have selected Immunisation, please fill out details below

Myself

Whanau

Tamariki

GP Name & Contact (if avaliable)

You have selected Immunisation, please fill out details below

Reason for Referral

Please describe the key issues, needs or areas where support is required. Attach supporting documents if needed:

File

Max. file size: 63 MB.

What outcomes is the referrer or individual/whānau hoping to achieve?

Cancer Care

You have selected Cancer Care, can you please provide the details below:

Next of Kin: Name

Next of Kin: Phone Number

Next of Kin: Relationship

Name of Doctor / Medical Centre

Number of Medical Center

Name of specialist (if known)

Do you have a vision or hearing impairment? Detail below:

What is your medical diagnosis?

What treatment have you had so far?

Are you smoker?

Yes

Is this your first time registered with us?

Yes

How may we assist you? (Support, Finances, Advocacy, Transport)

Housing Status:

e.g. private rental, housing NZ

Housing Alerts:

e.g. infections, dogs, allergies, safety risks

Income source:

e.g. employed, benefit etc.

Driving Education

You have selected Driving Education, can you please provide the details below:

Current Drivers Licence (if any)(Required)

None

Learner Licence

Restricted Licence

Full Licence

Are you interested in doing a Defensive Driving Course?

Yes

Functional Family Therapy

You have selected Functional Family Therapy, can you please answer the following questions:

Reason for Referral (Oranga Tamariki):

Referral to ensure that all the correct information is being captured, the Young Person must be between the ages of 10 to 17 years? What Behaviour concerns is being presented by the young person and the primary caregiver?

Clinical Behaviour symptoms: (Please enter details)

Hinengaro (do you have any of the following conditions):
Maladaptive behaviour, Trauma (Intergenerational or systemically), Mental Health (anxiety, depression), Environmental Factors, Biological factors, YP on the spectrum:
ADHA, ASD, ODD, mild Autism (Non-Verbal Autism, Suicide Ideation and Psychosis is not considered) example: Self-Medicating, Marijuana, Meth and other drugs, Huffing:

Care and Protection or Youth Justice: (Please identify the following)

Juvenile Behaviour (Has the Youth Participant previously offended in unlawful behavior) example: Shoplifting, stealing, attempting to take a vehicle:

Additional Information

Cultural or spiritual considerations:

Current service providers involved:

Safety concerns or risk factors:

Other relevant information:

Consent Declaration

Consent Form – Te Rūnanga o Ngā Maata Waka

Puka Whakaae – Tuku Tūtohu ki Te Rūnanga o Ngā Maata Waka

This form confirms that informed consent has been given for a referral to Te Rūnanga o Ngā Maata Waka, either by the individual themselves or through a referrer with verbal consent. It outlines how personal information will be collected, used and protected in line with the Privacy Act 2020, the Data Protection and Use Policy (DPUP).

Purpose of the Referral | Te Pūtake

This referral is made to help connect the client with support or services provided by Te Rūnanga o Ngā Maata Waka. We respect the client’s Mana Whakahaere their right to understand and choose what happens to their information.

Use of Personal Information | Te Whakamahi i ngā Mōhiohio Whaiaro

We collect personal information including your:

• Name

• Date of birth

• Contact details

• Ethnicity and gender

• Health, education or justice-related information (depending on the service)

• Employment or income details (where applicable)

• Other information relevant to support your referral and needs assessment

We use this information to:

• Connect you to services that support your goals

• Understand your needs and provide the right support

• Undertake research to improve services (using de-identified information)

• Ensure we are meeting the requirements of our funders and partners

• Report to our funders and commissioning agencies in a way that demonstrates service delivery and outcomes

• Contribute to broader research and evaluation (with de-identified data only)

If you are providing information about another person (for example, a whānau member), you must have their consent to do so and ensure they understand how their information may be used.

We respect your Mana Whakahaere your right to understand and choose what happens to your information.

Who We May Share Your Information With

Your information will be stored securely in encrypted systems, accessed only by authorised staff. Information may be shared with:

• Te Tauraki – to monitor and fund services

• Te Puni Kōkiri – for service evaluation (only summarised, high-level information)

• Stats NZ – for research using the Integrated Data Infrastructure (IDI), with all personal identifiers removed

• Ministry of Social Development (MSD) – For employment, whānau resilience, or social service contracts

• Ministry of Justice – For justice, court-based or family violence-related services

• Oranga Tamariki – For tamariki and rangatahi-related services

• Ministry of Health / Te Whatu Ora – For health service coordination and funding purposes

• NZ Corrections – For reintegration or corrections-based programmes

• Ministry of Education – For education, training, and youth service outcomes

• Approved community or support partners – When we have your consent to make a referral on your behalf

•Other funded agencies.

Any data used in the Integrated Data Infrastructure (IDI) will have personal identifiers removed. Research is conducted only at the group level—no individuals will ever be identified.

How We Protect Your Information

We take all reasonable steps to keep your information safe, including:

• Encrypted storage systems

• Restricted access to authorised staff only

• Secure transfer methods when sharing data

• Adherence to Privacy Act 2020 and any relevant regulations

We follow Kaitiakitanga (guardianship) and Manaakitanga (care and respect) in all data handling. We are committed to upholding the principles of Te Tiriti o Waitangi and ensuring that your cultural needs are respected in the way we collect and use your information.

If you do not wish to provide your information or co-develop a support plan, we may not be able to offer you services. Many of our services require personal information to meet eligibility and safety requirements.

Your Rights | Mātou Motika

You can:

• Request access to your personal information

• Ask for corrections if information is incorrect

• Decline or withdraw consent at any time

• Ask questions about how your information is used

To make a request, contact us at:

Email: info@ngamaatawaka.org.nz

Phone: 03 382 6628

Post: 250 Pages Rd, Aranui Christchurch

Photographs and Media | Te Whakamahi i ngā Whakaahua me te Pāpāho

The client has been informed that photographs or videos may be taken during events or programmes. These may be used in reports, newsletters, promotional materials, or social media.

Consent for image use is voluntary and can be withdrawn at any time without affecting access to services.

Hidden

Consent Form – Te Rūnanga o Ngā Maata Waka

Puka Whakaae – Tuku Tūtohu ki Te Rūnanga o Ngā Maata Waka This form confirms that informed consent has been given for a referral to Te Rūnanga o Ngā Maata Waka, either by the individual themselves or through a referrer with verbal consent. It outlines how personal information will be collected, used and protected in line with the Privacy Act 2020, the Data Protection and Use Policy (DPUP). Purpose of the Referral | Te Pūtake This referral is made to help connect the client with support or services provided by Te Rūnanga o Ngā Maata Waka. We respect the client’s Mana Whakahaere their right to understand and choose what happens to their information. Use of Personal Information | Te Whakamahi i ngā Mōhiohio Whaiaro We collect personal information including your: • Name • Date of birth • Contact details • Ethnicity and gender • Health, education or justice-related information (depending on the service) • Employment or income details (where applicable) • Other information relevant to support your referral and needs assessment We use this information to: • Connect you to services that support your goals • Understand your needs and provide the right support • Undertake research to improve services (using de-identified information) • Ensure we are meeting the requirements of our funders and partners • Report to our funders and commissioning agencies in a way that demonstrates service delivery and outcomes • Contribute to broader research and evaluation (with de-identified data only) If you are providing information about another person (for example, a whānau member), you must have their consent to do so and ensure they understand how their information may be used. We respect your Mana Whakahaere your right to understand and choose what happens to your information. Who We May Share Your Information With Your information will be stored securely in encrypted systems, accessed only by authorised staff. Information may be shared with: • Te Tauraki – to monitor and fund services • Te Puni Kōkiri – for service evaluation (only summarised, high-level information) • Stats NZ – for research using the Integrated Data Infrastructure (IDI), with all personal identifiers removed • Ministry of Social Development (MSD) – For employment, whānau resilience, or social service contracts • Ministry of Justice – For justice, court-based or family violence-related services • Oranga Tamariki – For tamariki and rangatahi-related services • Ministry of Health / Te Whatu Ora – For health service coordination and funding purposes • NZ Corrections – For reintegration or corrections-based programmes • Ministry of Education – For education, training, and youth service outcomes • Approved community or support partners – When we have your consent to make a referral on your behalf • Other funded agencies. Any data used in the Integrated Data Infrastructure (IDI) will have personal identifiers removed. Research is conducted only at the group level—no individuals will ever be identified. How We Protect Your Information We take all reasonable steps to keep your information safe, including: • Encrypted storage systems • Restricted access to authorised staff only • Secure transfer methods when sharing data • Adherence to Privacy Act 2020 and any relevant regulations We follow Kaitiakitanga (guardianship) and Manaakitanga (care and respect) in all data handling. We are committed to upholding the principles of Te Tiriti o Waitangi and ensuring that your cultural needs are respected in the way we collect and use your information. If you do not wish to provide your information or co-develop a support plan, we may not be able to offer you services. Many of our services require personal information to meet eligibility and safety requirements. Your Rights | Mātou Motika You can: • Request access to your personal information • Ask for corrections if information is incorrect • Decline or withdraw consent at any time • Ask questions about how your information is used To make a request, contact us at: Email: info@ngamaatawaka.org.nz Phone: 03 382 6628 Post: 250 Pages Rd, Aranui Christchurch Photographs and Media | Te Whakamahi i ngā Whakaahua me te Pāpāho The client has been informed that photographs or videos may be taken during events or programmes. These may be used in reports, newsletters, promotional materials, or social media. Consent for image use is voluntary and can be withdrawn at any time without affecting access to services.

Consent Confirmation | Te Whakaae(Required)

I confirm that next of kin information has been shared with the client’s full knowledge and authorisation. The client understands and agrees that this information may be used for emergency contact, safety, or care coordination purposes.

I am the client or referrer and I confirm that informed consent has been given for this referral and for the collection, use and storage of personal information, as outlined above.

I confirm that the client has been informed of the purpose of this referral, how their personal information will be used, who it may be shared with, and their rights under the Privacy Act 2020 and DPUP. I confirm the client has given their informed consent for this referral and, if applicable, for photo/media use.

I do not consent to my (or the client’s) personal information being collected, used, or shared as outlined above.