The Pride Project Referral Form

TPP Referral Form

All information you share here will remain private and confidential.
Are you the person needing support?*

YESNO, I am referring someone. Go to Section 1
SECTION 1 - REFERRING SOMEONE

Complete this section only if you are referring someone. Then go to Section 2 to tell us what the person you're referring needs and their contact details in Section 3.
If you are referring someone. What agency or organisation are you from?
If other, what is the name of your organisation?
Referrers name:   First Name   Last Name
Referrers contact email?   Email
Contact phone number   Area Code   Phone Number
SECTION 2 - HOW CAN WE HELP?
What help or support is needed?
Have you worked with a Hope Navigator at the Pride Project before?*

NOYES
EVERYDAY LIVING

Housing advocacyBudgeting / Financial MentoringEssential needs, clothing, bills & kai povertyPride in your home, lawns maintenanceOther
FUTURE PLANNING

Vehicle licensingEmployment job searchEmployment prepEducation & Further trainingDigital LiteracyBusiness idea guidanceOther
OVERALL HEALTH & WELLNESS

Addictions servicesAnger ManagementMental Health supportDisability supportYou would like to be connected to Mobile GP Health servicesOther
SECTION 3 - TELL US ABOUT YOURSELF

The person needing support...
Name*
First and Last name
Address*

Include House number - Unit number (if applicable) - Street name

Suburb
Contact number *
Make sure your number is correct. We will contact you on this number within 24 hours Monday to Friday. If you make a request on Friday we will contact you on Monday.
Date of Birth*

DayMonthYear
Date
MSD Number (if you have one)
Gender

FEMALEMALEOTHER
Ethnicity*

MāoriPacificAsian (Pan-Ethnic Asian, Indian, Filipino)MELAA (Middle East / Latin America / Africa)European (Pakeha)
Iwi, Hapū Village (if applicable)
Marital Status*

SingleIn a relationshipMarried
Do you have transport?
Employment Status*
Is there anything further we should know?
Email
Are you in a Kainga Ora home?*

YESNO
Are you in prison or re-integrating into the community after being in prison?*

YESNO
Parenting*

Single ParentingSeparated but Co-ParentingGrandparent raising moko'sNot applicable
How many adults 18+ are living in your home?*
Number of Tamariki in your care under 5years old?*
Number of Tamariki in your care aged between 6 - 12 ?*
Number of Rangatahi in your care aged between 13 - 17 ?*
Is Oranga Tamariki involved?*

NOYES
IMMIGRATION STATUS (Required for data collection)*

NZ Citizen/ResidentTemporary VisaUnknownUndocumented
PRIVACY AND CONFIDENTIALITY CONSENT*

The Pride Project requires information and digital data about you to assess, provide and review appropriate services and for accountability purposes. In line with the Privacy Act, we will protect your privacy in the following ways:• We keep your information secure accessible only by staff who are authorised to and require access for a specific purpose only.• We will treat all information confidentially and will only ask for information or documents that we need to support you.• You can ask to see your file and request we correct any inaccuracies.• We will respond immediately if you believe we have not respected or kept your information private.• We keep your information for seven years at which point we will securely destroy it through secure document destruction.• Please be aware that Tangata Whaiora files are randomly selected for monitoring or audit purposes by accreditation and auditing agencies. These organisations must keep your information confidential.If you’d like to ask for a copy of your information, or to have it corrected, please contact our CE luella.linaker@theprideproject.co.nz
Should be Empty:

TPP Referral Form

SECTION 1 - REFERRING SOMEONE

SECTION 2 - HOW CAN WE HELP?

SECTION 3 - TELL US ABOUT YOURSELF