Mana Ake Programme Online Consent Form

Mana Ake Programme Online Consent Form

Supporting Wellbeing and Positive Mental Health for Tamariki in Years 1-8 Across Te Tai o Poutini, West Coast
Introduction

Mana Ake – Stronger for Tomorrow is a school-based service supporting the wellbeing and mental health of tamariki and their whānau. This form provides consent for your child to take part in Mana Ake programmes. Please complete all sections.
Tamariki (Child) Information
Tamariki Full Name:*

First NameMiddle NameLast Name
Date of Birth:*

MonthDayYear
Date
Current School:*
Year Level:*
Iwi (if applicable):
Ethnicity:*
Programme Consent

Mana Ake offers various wellbeing programmes within schools, including group and one-on-one support. By consenting to the programmes listed below, you allow your child to participate in the selected services.
Please select the programme you consent to for your child’s participation:*

I Am Valued - A classroom wellbeing programme covering self-esteem, communication, boundaries, resilience, and emotional regulation (6 sessions).Brave Brains - A group programme for tamariki aged 8-12 who experience anxious feelings, offering gentle ways to build confidence and self-calm (6 sessions).LEGO-Based Therapy - A therapeutic group using LEGO to build communication and teamwork skills in groups of three tamariki (30-minute sessions).Kapa hoa / Friendship and Social Skills Groups - Small groups focused on building empathy,conflict resolution, and social skills (Sessions can be tailor made to suit tamariki well-being).ACES - ACES uses a mixture of games, creativeactivities, and focused discussions to help children understand their feelingsand the different circumstances around the separation of their parents.
If you are interested in multiple programmes, please list the rest below:
I Am Valued - A classroom wellbeing programme covering self-esteem, communication, boundaries, resilience, and emotional regulation (6 sessions).*

YesNo
Seasons for Growth - A small group programme supporting children coping with change, loss, and grief (8 sessions).*

YesNo
Brave Brains - A group programme for tamariki aged 8-12 who experience anxious feelings, offering gentle ways to build confidence and self-calm (6 sessions).*

YesNo
LEGO-Based Therapy - A therapeutic group using LEGO to build communication and teamwork skills in groups of three tamariki (30-minute sessions).*

YesNo
Kapa hoa / Friendship and Social Skills Groups - Small groups focused on building empathy,conflict resolution, and social skills (Sessions can be tailor made to suit tamariki well-being).*

YesNo
Safety, Privacy, and Information Sharing

Mana Ake staff will collaborate with teachers, school staff, and external services to provide the best support for your child. Information may be shared among the Mana Ake team, school personnel, and relevant external providers to coordinate and enhance support. All information is securely handled in accordance with the Privacy Act 2020.
Acknowledgment & Consent*

I understand that information about my child’s support may be shared within the Mana Ake team and relevant school staff to ensure they receive appropriate care.I understand that Mana Ake will only collect, store, and share information necessary for supporting my child’s wellbeing and that records will be securely kept by Poutini Waiora.I consent to Mana Ake and Poutini Waiora sharing information with other services and organisations as needed to support my child’s wellbeing. This will be discussed with me before it occurs.
Programme Exclusions and Additional Support Needs
Are there specific programmes you do not want your child to participate in?*
Please specify any programme(s) you do not consent to and the reason, if applicable
Additional Information or Support Needs*
Provide any other relevant information or specify areas where additional support may be beneficial
Other Services
Are there any additional services or support needs that Poutini Waiora or Mana Ake can help address for your whānau?
Consent and Declaration

By signing below, I consent to Mana Ake providing the selected services to my child. I understand and agree to the terms of service, information-sharing practices, and privacy standards set out above. I also understand that I may withdraw my consent at anytime by contacting Mana Ake or Poutini Waiora directly.
Name of Parent/Guardian:*

First NameLast Name
Relationship to child:*
Email:*
example@example.com
Phone Number:*

Area CodePhone Number
Signature:*

Clear
Date:*

MonthDayYear
Date
School Principal Email (optional / if known):
example@example.com
Contact Information

If you have any questions about the consent process or Mana Ake’s services, please contact:

Phone: 0800 333 170
Email: enquiries@poutiniwaiora.co.nz or chelsea.sargeant@poutiniwaiora.co.nz
Website: www.poutiniwaiora.co.nz/ManaAke
Thank you for entrusting Mana Ake with your child’s wellbeing. We look forward to working together to support tamariki across Te Tai o Poutini.
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Mana Ake Programme Online Consent Form

Introduction

Tamariki (Child) Information

Programme Consent

Safety, Privacy, and Information Sharing

Programme Exclusions and Additional Support Needs

Consent and Declaration