A Girl Called Hope Engagement Form

Engagement Form
Kia ora!

We are so pleased that you have taken this step towards your wellbeing journey. Engaging with us is the beginning of working together to consider if we are a good fit for your needs.

Your questions and those of your whanau or key support people are very welcome throughout this process.

Engagement with us indicates you are:

· open to change,

· willing to try new solutions,

· wanting to practice reflection.

Engagement is voluntary and you can withdraw at any time. Your privacy is important to us, and what you share us will remain confidential to A Girl Called Hope.

This questionnarie is designed to assist you as we support you with the planning of your journey with us.

Our team is looking forward to connecting with you and exploring your wellbeing goals.
Your Personal Details
Name*

First NameLast Name
Email*
example@example.com
Phone Number (Mobile)*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

Town/CityRegion

Postal / Zip Code
Preferred way for us to contact you*
Age*

16-1718-2425-3435-4445-5455+
Gender*
Ethnicity*
Iwi
Hapu
Other Ethnicity
Connecting with us: If meeting online, for privacy we use end to end encryption apps to communicate electronically. What technology do you have available to communicate with our team?*

Mobile PhoneLaptop or PCTabletNone of these
How confident are you with using technology and learning new technology?*
Our normal working hours are Mon-Fri, 8am to 5pm. Is your situation flexible enough to allow you to access our supports during these hours?*
What times work best for you
Your Hauora

Our approach to Wellbeing is strongly informed by the Te Whare Tapa Wha model with its dimensions of hauora/wellbeing. The following questionnaire asks how you feel about your quality of life, health, or other areas. Please answer all of the questions, if you are unsure about a response please choose the one that appears most appropriate. This can often be your first response. We ask that you think about your life in the last two weeks.
1. Te Taha Tinana (Physical Wellbeing)
How satisfied are you with your health?*
How satisfied are you with your sleep?*
How satisfied are you with your capacity for work?*
Do you have enough energy for everyday life?*
To what extent does physical pain prevent you from doing what you want to do?*
Is your Taha Tinana (Physical Wellbeing) something you would like to work on?
2. Te Taha Hinengaro (Mental/Emotional Wellbeing)
How do you rate your quality of life?*
How much do you enjoy life?*
How well are you able to concentrate?*
Are you able to accept your bodily appearance?*
Do you have capacity for leisure activities?*
How satisfied are you with yourself?*
Is your Taha Hinengaro (Mental and Emotional Wellbeing) something you would like to work on?
3. Te Taha Whanau(Social/Family Wellbeing)
How satisfied are you in your personal relationships?*
How satisfied are you with the support you get?*
How safe do you feel in your daily life?*
How available to you is the information that you need in your day to day life?*
Is your Taha Whānau (Family and Social Wellbeing) something you would like to work on?
4. Te Taha Wairua(Spiritual Wellbeing)
To what extent do you feel your life is meaningful?*
To what extent does nature play a part in your life?*
Do you feel connected to anything higher than yourself?*
How satisfied are you with your spirituality?*
Is your Taha Wairua (Spiritual) something you would like to work on?
Are there any cultural considerations that are important to you, which would be helpful to know in our mahi (work) with you?
5. Services I would like to engage with.
Please indicate which of these services you are interested in:

CounsellingWellbeing CoachingWellbeing courses
6. Other Information
How did you hear about us?

Family or Friend/sRadio/TVSocial MediaChurchOnline platformsOther
Kaupapa
Our desire is that everyone who engages with us would experience unconditional love, and transformative change, resulting in freedom; this is our Christian environment, our Kaupapa. As a part of our commitment to reduce financial barriers for participants, we provide our services on a donation basis.*

I have read and understood this
Privacy
Privacy: A Girl Called Hope collects and stores information from this form to assess suitability and inform our ongoing work with you while you are engaged with our organisation. Any personal information you provide is collected, held, handled, used and disclosed in accordance with the 12 information privacy principles of The Privacy Act (2020) which can be viewed on the Privacy Commissioner’s website.*

I have read and understood this
*Adapted from the World Health Organisation Questionaire (Field Trial Version Dec 1996)
Should be Empty:

Engagement Form

Your Personal Details

Your Hauora

1. Te Taha Tinana (Physical Wellbeing)

2. Te Taha Hinengaro (Mental/Emotional Wellbeing)

3. Te Taha Whanau(Social/Family Wellbeing)

4. Te Taha Wairua(Spiritual Wellbeing)

5. Services I would like to engage with.

6. Other Information

Kaupapa

Privacy