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Pae Ora ERMS additional questions
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Pae Ora ERMS additional questions
Pae Ora ki Waitaha Referral form for ERMS
The service is for those who are part of one of the following communities:
Māori
Pasifika
Remote rural
Culturally and linguistically diverse (CALD)
LGBTQIA+ community
AND
If 25 years and over – have a lifestyle-related physical health condition and are willing to make lifestyle changes
If Rangatahi (13 – 24 years ) – have or are at risk of developing a lifestyle condition and are willing to make lifestyle changes
If Tamariki (4-12 years) – have or at risk of developing a lifestyle related health condition and with whānau willing to make lifestyle changes
Pae Ora is available to all people meeting these criteria, including those with disability or mental illness, however, please note that the intention of Pae Ora is to meet the needs of those seeking support for physical health improvement relating to lifestyle conditions. *Note that disability and mental illness are not exclusion criteria, however, the individual should meet the definition of experiencing a physical health condition (or at risk of developing) in which lifestyle is a contributing factor. *At risk includes lifestyle factors that increase risk of developing Diabetes, Cardiovascular or Respiratory conditions
Lifestyle related physical health condition(diabetes, high blood pressure, high cholesterol etc)
(Required)
Hidden
Date of referral
DD slash MM slash YYYY
Hidden
Type of referral
Please Select
Agency/Professional
Self
Whanau Member
Hidden
Consent to referral
Please Select
Yes
No
Client Details
Please ensure you have consent to refer. Under 16's require parental consent.
NHI number
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Ethnicity
(Required)
Please Select
NZ Maori
NZ European
Chinese
Pacific Island
Indian
Other ( Please specify below)
Unknown
Iwi (You can select multiple Iwi)
Kāti Māmoe
Moriori†
Muaūpoko
Ngā Rauru
Ngāi Tahu / Kāi Tahu
Ngāi Tai ki Tāmaki
Ngāi Tai (Tauranga Moana/Mātaatua)
Ngāi Takoto
Ngāi Tāmanuhiri
Ngāi Te Rangi
Ngāpuhi
Ngāpuhi / Ngāti Kahu ki Whaingaroa
Ngāruahine
Ngāti Apa ki te Rā Tō
Ngāti Apa (Rangitīkei)
Ngāti Awa
Ngāti Hako
Ngāti Hāua (Taumarunui)
Ngāti Hauā (Waikato)
Ngāti Hauiti
Ngāti Hei
Ngāti Hinerangi
Ngāti Kahu
Ngāti Kahungunu ki Heretaunga
Ngāti Kahungunu ki Tamakinui a Rua
Ngāti Kahungunu ki Tamatea
Ngāti Kahungunu ki Te Wairoa
Ngāti Kahungunu ki Te Whanganui-a-Orotu
Ngāti Kahungunu ki Wairarapa
Ngāti Kauwhata
Ngāti Koata
Ngāti Kuia
Ngāti Kurī
Ngāti Manawa
Ngāti Maniapoto
Ngāti Maru (Hauraki)
Ngāti Maru (Taranaki)
Ngāti Mutunga (Taranaki)
Ngāti Mutunga (Wharekauri/Chatham Islands)
Ngāti Pāhauwera
Ngāti Pāoa
Ngāti Pikiao (Te Arawa)
Ngāti Porou
Ngāti Porou ki Hauraki
Ngāti Pūkenga
Ngāti Pūkenga ki Waiau
Ngāti Rāhiri Tumutumu
Ngāti Rākaipaaka
Ngāti Rangi
Ngāti Ranginui
Ngāti Rangiteaorere (Te Arawa)
Ngāti Rangitihi (Te Arawa)
Ngāti Rangiwewehi (Te Arawa)
Ngāti Rārua
Ngāti Raukawa (Horowhenua/Manawatū)
Ngāti Raukawa (Waikato)
Ngāti Ruanui
Ngāti Tahu – Ngāti Whaoa (Te Arawa)
Ngāti Tama ki Te Upoko o Te Ika
Ngāti Tama Kopiri (Taihape)
Ngāti Tama (Taranaki)
Ngāti Tama (Te Waipounamu/South Island)
Ngāti Tamaterā
Ngāti Tara Tokanui
Ngāti Toarangatira (Te Waipounamu/South Island)
Ngāti Toarangatira (Te Whanganui-a-Tara/Wellington)
Ngāti Tūmatakōkiri
Ngāti Tūwharetoa
Ngāti Wai
Ngāti Whakaue (Te Arawa)
Ngāti Whanaunga
Ngāti Whare
Ngāti Whātua
Pakakohi
Rangitāne (Manawatū)
Rangitāne (Te Matau-a-Māui/Hawke's Bay/Wairarapa)
Rangitāne (Te Waipounamu/South Island)
Rongomaiwahine
Rongowhakaata
Tangāhoe
Tapuika (Te Arawa)
Taranaki
Tarāwhai (Te Arawa)
Te Aitanga-a-Māhaki
Te Ati Haunui-a-Pāpārangi
Te Atiawa ki Whakarongotai
Te Atiawa (Taranaki)
Te Atiawa (Te Waipounamu/South Island)
Te Atiawa (Te Whanganui-a-Tara/Wellington)
Te Aupōuri
Te Kawerau ā Maki
Te Patukirikiri
Te Rarawa
Te Roroa
Te Uri-o-Hau
Te Whānau-a-Apanui
Tūhoe
Tūhourangi (Te Arawa)
Uenuku-Kōpako (Te Arawa)
Waikato
Waitaha (Te Arawa)
Waitaha (Te Waipounamu/South Island)
Whakatōhea
Pasifika (You can select multiple)
Cook Islands Māori
Fijian
Niuean
Rotuman
Samoan
Soloman
Tokelauan
Tongan
Hapu
Preferred Language
Preferred Pronoun
Preferred method of contact:
Please include preferred day, time of day if appropriate, hearing/vision impairment(s) etc.
Referral Details
Other programmes/services currently involved in:
Preferred provider
(Required)
Please Select
Purapura Whetu Trust (Kaupapa Māori Health and Social Services)
Whānau Whanake
Waitaha Primary Health
Tangata Atumotu Trust
'Not sure / don't mind
We will do our best to match accordingly. If no provider is indicated, a provider will be chosen on acceptance of the referral.
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