Ki te kore ngā pūtake e mākūkūngia e kore te rākau e tupu
If the roots of the tree are not watered the tree will never grow.

Kia ora! Te Pūtahitanga o Te Waipounamu want to check-in with you, and see if we can help you and your whānau in any way through the COVID-19 pandemic.

Please give as much information as you can. It's important that you complete as many details, so that we can help you.

It is important for you to know that when giving your information to us, you authorise the release of, and use of, your personal information to and by our kaimahi and those we partner with for the purposes of supporting you during the COVID-19 event. We'll use the information you tell us to inform our Manaaki 20 planning, our communications and our reporting.

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* 1. Contact details

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* 4. How many whānau members in your house/whare during the isolation period are aged 60 and above?
Please enter a whole number.

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* 5. What is your date of birth?

Date

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* 6. What ethnicities do you identify with? (Please tick all that apply)

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* 7. Which iwi do you identify with? (Please tick as many as apply)

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* 8. Are you enrolled with your GP, and could you please provide the contact details?

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* 9. Has anyone in your household/whare been unwell recently over the last week?

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* 10. Has anyone in your household returned from overseas in the last month/two weeks/week?

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* 11. Is anyone in your household/whare on medications? 

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* 12. Have you had the flu vaccination?

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* 13. Do you receive meals on wheels or other food service?

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* 14. Do you get home help that you rely on?

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* 15. Do you have people you are able to be in contact with daily (daughter/health worker/cousin)?

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* 16. Do you have access to the following?

  Yes  No
Sufficient kai for four weeks
Soap
Telephone
Internet
Confident to communicate online using the computer/mobile
A Whānau Ora navigator

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* 17. What are your main concerns for you and your whānau at this time?

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* 18. Is there anything you think we could help you with immediately?

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* 19. What's helping your whānau to get through this?

If your situation changes or you want to talk to us for any reason you can get back in touch with us through the number- 0508 4 manaaki [0508462622]

Kia hora te marino,
Kia whakapapa pounamu te moana
Te tapu o te tangata- All life is sacred

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