Request to Join SkillWise
Fields marked with a red arrow must be completed.
This form is written with the intention that the person completing it is the person who wishes to join SkillWise. If you are completing the form on behalf of someone else, please provide their details.
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If you are filling in this form on behalf of someone else, please provide your name and contact details:
First Name
Surname
Please indicate what support you are interested in Please select at least one value for "Please indicate what support you are interested in".
Your phone number | ![]() Your cell phone number |
Your email address
Your date of birth | Gender Please select at least one value for "Gender". |
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Ethnicity
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Iwi:
WINZ number
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Do you have any of the following: New Zealand Citizenship / New Zealand Residency / New Zealand Work Visa
Do you have a disability and/or health condition that is/are likely to continue for a minimum of six months Please select at least one value for "Do you have a disability and/or health condition that is/are likely to continue for a minimum of six months".
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Can you please give us some details about any disability or health condition that you have?
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Please indicate which of these terms describe your intellectual disability (you can select more than one)
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I am eligible for funding from
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If EGL is yes, who is your Life Links Co-ordinator
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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*
Do you receive support from another disability provider? Please select at least one value for "Do you receive support from another disability provider?".
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If you answered yes, please tell us the names of any other providers you receive support from
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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.
I have high and complex needs Please select at least one value for "I have high and complex needs".
About me and my life
The best way to communicate with me: Please select at least one value for "The best way to communicate with me:".
I may need support with
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Things I do now
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New things I would like to try/do with support from SkillWise or my community
Important People
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I live with family / in my own home (independent) / with a residential provider (residence)
Do you have a Welfare Guardian? Please select at least one value for "Do you have a Welfare Guardian?".
Details of key contact person
First Name
Surname
Their phone number | ![]() Their cell phone number |
Their email address
Their relationship to you?
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If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)
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If this person is your Welfare Guardian, what information are you happy for us to share with them?
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What date will the Welfare Guardian powers be reviewed?
Details of a second contact person
First Name
Surname
Their phone number | ![]() Their cell phone number |
Their email address
Their relationship to you?
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If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)
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If this person is your Welfare Guardian, what information are you happy for us to share with them?
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What date will the Welfare Guardian powers be reviewed?
Who is your family/whanau contact (if not one of the above)
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First Name
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Surname
![]() Their phone number | ![]() Their cell phone number |
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Their email address
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Their relationship to you
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If this person is your Welfare Guardian, what responsibilities do they have? (select all that apply)
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If this person is your Welfare Guardian, what information are you happy for us to share with them?
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What date will the Welfare Guardian powers be reviewed?
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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.
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I give SkillWise permission to seek and share information about my medical history, health needs and education
I consent to SkillWise using photograph or videos of me Please select at least one value for "I consent to SkillWise using photograph or videos of me".
Please 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.
Who is your current doctor/medical centre
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What is their phone number
![]() Do you have any allergies | ![]() Do you currently take any medication? |
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If yes, can you tell us what the medication is and what it is for?
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Do you need help to administer your medication?
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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.
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Do you have epilepsy or experience seizures?
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Do you have diabetes?
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Do you have a hearing impairment?
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Do you have a visual impairment?
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Do you require assistance with speech and verbal communication?
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Do you have a physical disability or difficulty with walking / moving?
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Do you have asthma?
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Do you have any other medical conditions? Please select from the options below
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Do you have angry outbursts?
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Do you get panic attacks?
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Please tell us about any mental health issues you may have. Select from the options below
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Do you need support around staying clean and healthy (i.e. personal hygiene)?
Are there any behavioural or health issues we should know about? Please select at least one value for "Are there any behavioural or health issues we should know about?".
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If yes, please describe these including any triggers and/or warning signs
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Please describe any strategies/steps to help maximise your health and wellbeing
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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
Is it safe for you to drink alcohol? Please select at least one value for "Is 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