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Peer Support Course Enrolment - Expression of Interest
Thank you for expressing an interest in the Making Headway 10-week programme.
Enrolment is subject to screening by staff to ensure that everyone finds the course beneficial. A staff member will contact you to discuss.
Name
First name
Last name
Email address
Phone Number
*
Area of Auckland I live in
Central Auckland
East Auckland
Northshore
South Auckland
West Auckland
North Auckland
Date of Birth
Ethnicity
Maori
Pākehā/NZ European
Pasific People
Chinese
Asian
European
Sth American
Indian
Middle Eastern
Other
Gender
Female
Male
Non Binary
Organisation
Cause of Injury
Accident/Traumatic Brain Injury
Sports Related
Stroke
Medical/Non Accident
No Brain Injury
Other
Injury Date
Is there anything we should know so we can best support you?
How did you hear about us?
Media
GP
DHB/Hospital
Rehab/Allied Health Professional/Health Professional
Family/Friend Recommendation
ACC/WINZ/Government Agency
Community Network
Self Referral
Internet Search/Google etc
Social Media
Research community
Headway - at expo or community event
Volunteering Auckland
Other
I give permission for you to contact my whānau/support person about my enrolment
Yes
No
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My Whānau
Name
First name
Last name
Email address
Phone
Group
Whānau
Ethnicity
Maori
Pākehā/NZ European
Pasific People
Chinese
Asian
European
Sth American
Indian
Middle Eastern
Other
Unknown
Ōrganisation
Relationship to you
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Did a health professional refer you to Headway?
Yes
No
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Referrer/Health Professional
Name
First name
Last name
Email address
Phone
Professional Role
ADHB
CMDHB
WDHB
Agencies Staff
Board Member
CEO/Manager
Clinical Lead
Doctor/Specialist
Educator
Funders/Trust
Neuropyschologist
Nurse
Occupational Therapist
Physiotherapist
Psychologist
SLT
Social Worker
Support worker
Team leader
Group
Health Professionals
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- Remove
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Please check the highlighted fields
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