Referrals Form

Privacy Statement for Collection of Personal Information

Te Hau Āwhiowhio o Otangarei Trust is a Not for profit - Urban Maori Provider that has a number of services some of which are contracted through Government Contracting. Our contracts require that we collect some information about your family/whānau during our service provision Pathway.

The Privacy Act 2020 requires us to tell you that:
- This information is being collected to provide Trust services to you and your family/whānau.
- Your personal information will only be shared with agencies/services involved in your case, or if we are required by law to release that information.

Under the Privacy Act 2020, you have the right to request in writing the information Te Hau Āwhiowhio o Otangarei Trust holds about you and to ask us to correct that information.

Giving your consent
This consent form sets out the choices you have when you engage with the Trust services process. It also explains how your personal information will be used. If you do consent to your information being shared, you have the right to change your mind at any time.

I understand and agree that:
1. The person/agency, service organising the meeting has explained the Trust process and its possible benefits to me.
2. I can decide to no longer take part in the Trust services at any time.
3. Information about my whānau/family’s Te Hau Āwhiowhio o Otangarei Trust process will be used for statistical purposes, but only information that does not identify any member of my family/whānau.
4. The referring Kaimahi explained the complaints process to me. If I make a complaint, Kaimahi that take part in Te Hau Āwhiowhio o Otangarei Trust Pathway will follow their Organisation complaint procedure.
5. My family/whānau can choose to bring support people to the meeting/appointment.
6. I can make suggestions about the meeting venue, cultural protocol to follow at the meeting, and any other needs I may have, such as translators, disability access, etc.
7. I am entitled to a copy of this consent form.

I acknowledge that the information contained herein is confidential and, pursuant to the Privacy Act 2020, will only be strictly used by the Te Hau Awhiowhio o Otangarei Trust team to effectively care for myself and/or my child and not used or distributed for any other purposes. Representatives from the social services procurement team which includes the Ministry of Social Development, Te Kāhui Kāhu Social Services Accreditation and Oranga Tamariki may view this information as part of the programme assessment process.