Request to Join SkillWise

Fields marked with a red arrow must be completed.

RequiredFirst Name
 
RequiredSurname
 
RequiredPlease indicate what support you are interested in


 
Your Address
RequiredAddress line 1
 
RequiredSuburb
 
RequiredTown/City
 
RequiredPostcode
 
RequiredYour phone number
 
Your cell phone number
 
RequiredYour email address
 
RequiredYour date of birth
 
RequiredGender
 
What is your preferred pronoun? (How should we address you?)
 
Ethnicity
 
RequiredWINZ number
 
Do you have any of the following: New Zealand Citizenship / New Zealand Residency / New Zealand Work Visa
 
RequiredDo you have a disability and/or health condition that is/are likely to continue for a minimum of six months
 
Can you please give us some details about any disability or health condition that you have?
 
Please indicate which of these terms describe your intellectual disability (you can select more than one)



















 
I am eligible for funding from




 
If EGL is yes, who is your Life Links Co-ordinator
 

Please indicate what type of assistance you are receiving from Work and Income?

*You will need to provide a copy of your Work and Income benefit letter as proof of identity*



 
RequiredDo you receive support from another disability provider?
 
If you answered yes, please tell us the names of any other providers you receive support from
 

Are you funded under a MOH Deinstitutionalisation process? 

Please only select this box if you receive a MOH Deinstitutionalisation package, do not select this box if you have MOH residential care subsidy.

 
RequiredI have high and complex needs
 
About me and my life                                                                                                                         
RequiredThe best way to communicate with me:
 
RequiredI may need support with
 
Things I do now
 
New things I would like to try/do with support from SkillWise or my community
 
Important People                                                                                                                               
I live with family / in my own home (independent) / with a residential provider (residence)
 
RequiredDo you have a Welfare Guardian?
 
Details of key contact person
RequiredFirst Name
 
RequiredSurname
 
Their postal address
RequiredAddress line 1
 
RequiredSuburb
 
RequiredTown/City
 
RequiredPostcode
 
RequiredTheir phone number
 
Their cell phone number
 
RequiredTheir email address
 
RequiredTheir relationship to you?
 
If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)

 
If this person is your Welfare Guardian, what information are you happy for us to share with them?






 
What date will the Welfare Guardian powers be reviewed?
 
Details of a second contact person
RequiredFirst Name
 
RequiredSurname
 
Their postal address
RequiredAddress line 1
 
RequiredSuburb
 
RequiredTown/City
 
RequiredPostcode
 
RequiredTheir phone number
 
Their cell phone number
 
RequiredTheir email address
 
RequiredTheir relationship to you?
 
If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)

 
If this person is your Welfare Guardian, what information are you happy for us to share with them?






 
What date will the Welfare Guardian powers be reviewed?
 
Who is your family/whanau contact (if not one of the above)
First Name
 
Surname
 
Their postal address
Address line 1
 
Suburb
 
Town/City
 
Postcode
 
Their phone number
 
Their cell phone number
 
Their email address
 
Their relationship to you
 
If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)

 
If this person is your Welfare Guardian, what information are you happy for us to share with them?






 
What date will the Welfare Guardian powers be reviewed?
 
Is there anyone else we should know how to contact?
 

Media and Information release                                                                                                          

We need your permission to use your image in promotion and to seek other information about you. Please answer yes or no.

Please refer to our Privacy Statement on our website: www.skillwise.org.nz for details about how we will handle your information. 

 

I give SkillWise permission to seek and share information about my medical history, health needs and education
 
RequiredI consent to SkillWise using photograph or videos of me
 
RequiredPlease indicate where we can use your image to promote SkillWise





 

Safety and Wellbeing                                                                                                                         

We need some information to help ensure the best ways to support you. Please answer the following questions.

 

RequiredWho is your current doctor/medical centre
 
What is their phone number
 
Do you have any allergies
 
Do you currently take any medication?
 
If yes, can you tell us what the medication is and what it is for?
 
Do you need help to administer your medication?
 

Please indicate if you have received the COVID-19 Vaccination.

Note: vaccination status does not impact on your eligibility to join SkillWise but may determine how we deliver support to you.

 
Do you have epilepsy or experience seizures?
 
Do you have diabetes?
 
Do you have a hearing impairment?
 
Do you have a visual impairment?
 
Do you require assistance with speech and verbal communication?
 
Do you have a physical disability or difficulty with walking / moving?
 
Do you have asthma?
 
Do you have any other medical conditions? Please select from the options below























 
Do you have angry outbursts?
 
Do you get panic attacks?
 
Please tell us about any mental health issues you may have. Select from the options below














 
Do you need support around staying clean and healthy (i.e. personal hygiene)?
 
RequiredAre there any behavioural or health issues we should know about?

 
If yes, please describe these including any triggers and/or warning signs
 
Please describe any strategies/steps to help maximise your health and wellbeing
 
Do you have any recent plans or assessments that you would like to share with us so that we can support you better? Please upload these files here if you wish
 
RequiredIs it safe for you to drink alcohol?
 

Please press 'Done' to submit your completed form. You will receive an email response when we have received your information.

If you have Enabling Good Lives (EGL) or Flexible Disability Support (FDS) funding, we require more details from you. We will send you an additional form which must be completed before we can accept you into our service.

Thank you

           
Need help completing this survey? Call 03 382 0350 or email info@skillwise.org.nz for assistance. Thanks