Pathways to Hope Application

Kia ora!

We are so pleased that you have taken this step to see if Pathways to Hope can be part of your wellbeing journey. Your decision to apply is the beginning of us working together to consider if the Pathways to Hope programme is a good fit for your needs.

It is important that you make an informed decision about seeking our help. Your questions and those of your whanau or key support people are very welcome throughout this process.

The Pathways to Hope programme requires you to:

· be open to change,

· be willing to try new solutions,

· engage in reflection.

It’s important that you are applying for yourself, without feeling pressured by others. If you don’t feel like this is the right ‘fit’ for you right now, you can come back to this when you feel ready.

Everything you tell us will be strictly confidential to A Girl Called Hope. Your information will not be shared with anyone else without your explicit permission. The exception to this is if what you tell us relates to potential danger to yourself or to others, then by law, we are required to report this; we would make every reasonable effort to speak with you about it first.

Pathways to Hope is a voluntary programme and you can withdraw your application at any time. As we regularly review the programme’s suitability to meet an applicant’s current needs, we reserve the right to discontinue your application process at any time.

Our team is looking forward to receiving your application and discussing your wellbeing goals with you.

I have read and understood the above

Yes

Name*

First NameLast Name

Name you go by (if different from above)

First NameLast Name

Email*

example@example.com

Phone Number (mobile)*

Area CodePhone Number

Phone Number (alternative)

Area CodePhone Number

The best way to contact you:

Home Address*

Street Address

Street Address Line 2

SuburbCity

Postal Code

Date of Birth*

Date

Age*

Gender*

Ethnicity*

Iwi:

Hapu

I feel that my relationships with others and my sense of connectedness with other people is currently:*

Is your Taha Whanau - Family and Social Wellbeing, something you would like to work on? *

What might you like to work on regarding your Taha Whanau - Family and Social Wellbeing?

Connecting with us: If meeting online, for privacy we use end to end encryption apps to communicate electronically, in particular Zoom or WhatsApp for video calls. What technology do you have available to communicate with our team?*

Mobile PhoneTabletLaptop or PCNone of these

How confident are you with using technology and learning new technology*

We operate Mon-Fri, 8am to 5pm. Is your situation flexible enough to allow you to access our supports during these hours?*

What times would you be available?

I feel that my mental and emotional wellbeing is currently:*

Is your Taha Hinengaro - Mental and Emotional Wellbeing, something you would like to work on? *

What might you like to work on to improve your Taha Hinengaro - Mental and Emotional Wellbeing?

Have you struggled with, been diagnosed or treated for any mental health related challenges?(e.g anxiety, depression)

What are your mental health challenges?

Do you have any learning-related challenges?

What learning challenges do you experience? *

I feel that my Physical wellbeing is currently:*

Is your Taha Tinana - Physical wellbeing, something you would like to work on?*

What might you like to work on to improve your Taha Tinana - Physical wellbeing?*

Are you on any medication that is related to your wellbeing?

I feel that my Spiritual wellbeing is currently:*

Is your Taha Wairua - Spiritual Wellbeing; life meaning and purpose, something you would like to work on?*

What might you like to work on to improve your Taha Wairua - Spiritual Wellbeing; life meaning and purpose?

Are there any cultural considerations that are important to you, which would be helpful to know in our mahi (work) with you?

I have read and understand the Kaupapa for Pathways to Hope*

How did you hear about A Girl Called Hope?*

How did you hear about us?

As a part of our commitment to reduce financial barriers for participants, we provide the Pathways to Hope programme on a donation basis. We invite all participants and their support people to donate. This will be discussed further with you at the next step of the application process and does not impact on your acceptance to the programme*

I have read and understood this

I have read and understood the completed application statement*

Yes

Signature

Name

Date

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 privacy statement.

Pathways to Hope Application

Your Personal Details

Your Hauora

1. TAHA WHANAU - Family and Social Wellbeing; a sense of connectedness.

2.TAHA HINENGARO - Mental and Emotional Wellbeing.

3. TAHA TINANA - Physical Wellbeing.

4. TAHA WAIRUA - Spiritual Wellbeing; life meaning and purpose.

Kaupapa

5. OTHER INFORMATION

Completed Application Statement