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MCH CARE project referral form
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* Indicates required question
Email
*
Your email
What is your full name?
*
Your answer
What is your preferred name/nickname you'd like us to use?
Your answer
Which MCH project are you signing up for?
*
Te Tairāwhiti/Gisborne (September 2022)
Wellington (Xmas workshop - December 2022)
Required
Have you had experience in the justice system?
Have you served / are you currently serving a sentence?
Yes
No
Clear selection
What is your probation officer's name? (If you have one)
Your answer
What is your contact phone number?
*
Your answer
What is your email?
*
Your answer
What is your age?
*
Your answer
What is your ethnicity or ethnicities? (include Iwi if applicable)
*
Your answer
Have you worked with Home Ground before? Choose all that apply
Tahi
Rua
Toru
Whā
MCH workshop
Arohata workshop
No
Other than Home Ground, have you ever done an art project before? If you have, please give a brief description of the project.
Your answer
Do you have a favourite type of art E.g. music, dance, carving, weaving, writing poetry?
Your answer
What is your main reason for signing up with Home Ground?
Your answer
What do you want to achieve by participating in this project?
Your answer
Do you have any medical or allergy concerns?
*
Your answer
Do you have any mental health concerns that we need to be aware of?
Your answer
Are you working with any reintegration services right now? (E.G Orongomai Marae, WOW, Salvation Army, PARS)
Your answer
Do you have any special requirements? E.g. panic attacks, an anger management plan, if so, please let us know so that we can support any specific requirements.
Your answer
Would you like support with learning? E.g. Reading, writing, comprehension, communication, if so, please let us know how we can help.
Your answer
Is there anything that might prevent you from attending all three days? E.g. a medical, legal or access issue.
Your answer
Do you have regular access to the internet and email?
Your answer
Is there anything else you would like us to know?
Your answer
Do you mind if we include your age and ethnicity as part of a group in Home Ground reports? Here is an example: "There were 10 women on the course, aged between 20-45. Five of the women identified as Māori, and five of the women identified as Pakeha."
*
Yes this is ok
No don't use my age or ethnicity
I'm not sure, I want to ask some questions
Thank you! 🥰✨🤩
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