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Early Years Support Pathway Registration of Interest Form

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We welcome your Registration of Interest for the Early Years Support Pathway funded by the Social Investment Agency. Before you register your interest, please read through the information about the service and the eligibility criteria. If you have not already read this information, you can access it (include link).
The purpose of the Registration of Interest is for us to identify families that are interested in this support and to collect enough information to determine whether our service is an appropriate fit for your whanau and child.

Please be aware that we are funded to provide support to a set number of whanau each year across the Wellington region. We anticipate there will be a greater number of families that meet our entry criteria than we will be able to support. By completing this form, you will be considered for our service along with all other whanau that apply.

After completing the form, you will be contacted within 4 weeks to let you know whether there is an available space. Given that we are not able to start services at the same time with all whanau, depending on your child's age, there may be instances where we can provide them service later in the year (2026). We encourage all families to continue to access all other appropriate supports in the meantime.

If you would like support to complete this form, please contact the Diagnosis and Early Support Coordinator by emailing: earlyyearspathway@autismnz.org.nz or calling 021 190 6053. If you are working with another provider, they may be able to support you to complete this form, or they can complete it on your behalf with your consent.

By completing this form, you hereby consent to Autism New Zealand collecting your data. (not sure what this actually means? Should it go elsewhere?)

Privacy Information:
  • Autism New Zealand collects personal information. (again, this seems vague, what does this mean for the whanau?)
  • Information requested and held is for the purposes of providing our services. It may also be used for statistical purposes in a way that doesn’t identify the individual.
  • The information collected will be held securely in our client database and information will remain confidential and available to the Autism New Zealand team only for at least 10 years. (who is the Autism NZ team?)
  • Providing information is optional however not providing some details may impact the services that we can offer you. (does it impact the service we can offer? Or whether we are able to determine appropriateness/meet service criteria/respond in a timely manner?)
  • You have the right to ask for a copy of any of the personal information and to ask for it to be corrected if you think it is wrong. (do we need this here?)
    Parent/caregivers/whānau full name (I'm not sure this is the correct use of the word whanau?)(Required.)
    Email address (parent/caregiver)(Required.)
    Mobile number (parent/caregiver)(Required.)
    Residential address (parent/caregiver)(Required.)
    Child/tamaiti full name(Required.)
    Child/tamaiti date of birth(Required.)
    Child/tamaiti gender(Required.)
    child/tamaiti ethnicity(Required.)
    What languages are spoken at home? (Required.)
    Does your child/tamaiti have an official autism diagnosis, if so by who (E.g Private practice, Child Development Services)(Required.)
    Does your child/tamaiti have another diagnosis? If so, what?(Required.)
    Does your child/tamaiti have any medical conditions we should be aware of? If so, what?(Required.)
    What ethnicity or ethnicities do you most identify with? (Please select all that apply.)
    What languages are spoken at home?
    Does your child have a formal autism diagnosis?
    If they have a diagnosis, where did they receive it? (Skip if they do not have a diagnosis)
    If they do not have a diagnosis, have they had a screening test for autism?
    If they do not have a diagnosis, are you interested in getting an assessment as part of this service?
    Does your tamaiti have any other diagnosis?
    Are they receiving services from any of the following providers?
    What type of service are they receiving? (Choose all that apply)
    Please indicate any developmental areas where your tamaiti/child needs support?
    Please let us know why you would like to access the Early Pathways Service and how it will support your tamaiti and whanau
    By completing this Registration of Interest, I agree that the information I have provided may be used for statistical and research purposes in a way that does not identify me, my child/tamaiti, or my whanau.

    If you are filling this out on behalf of a child/whanau, you agree that the family has been informed and agrees to the information being used for these purposes
    Our main form of initial contact of families will generally be via email. If you require another form of communication for cultural or accessibility reasons, please indicate below how we should contact you and why.
    If you are completing this form on behalf of a child/whanau, please write you name, email, and phone number, along with your role with the whanau