TE TŪĀPAPA AUAHA Healthy Lifestyles for Tamariki Rangatahi What is Te Tūāpapa Auaha and who is it for? Te Tūāpapa Auaha is a kaupapa Maori intervention weight management programme for our tamariki and rangatahi aged 0-18 with a BMI >28+. The programme is commissioned by the Bay of Plenty DHB and is managed and delivered by Te Puna Ora o Mataatua – covering the Eastern Bay of Plenty; Nga Kakano Foundation – covering Te Puke/Murupara and Ngati Ranginui Iwi – covering Tauranga and the Western Bay of Plenty. Who can refer? Referrals can be made by a GP or other health professional, school nurse, school health advisor or any other appropriate professional. Parental referrals are also accepted (as long as the tamariki or rangatahi meets the referral criteria. You can use this form to make a referral but before doing so please read and discuss the following with the tamariki/rangatahi and their parent/carer/whanau to ensure that they are aware of the commitment required. What’s the programme? • A pre programme consultation with the tamariki/rangatahi and their parent/carer/whanau • A 12 week physical activity & healthy eating/lifestyle education programme: The tamariki/rangatahi and their parent/carer/whanau meet to attend a weekly session which includes physical activity and practical cooking/ healthy eating advice (developed in conjunction with our Nutritionist). • On completion of this programme the tamariki/rangatahi will be required to attend 2 activity sessions per week for a further 12 weeks. • A post programme review (12 months after start) with the tamariki/rangatahi and their parent/carer/whanau. The review includes an exit strategy and sign posting to other appropriate programmes and activities. What level of commitment is required? • It is essential that the whanau are prepared to make lifestyle changes in and out of the home. • The tamariki/rangatahi and their parent/carer/whanau MUST attend the initial 12 week programme and the yearly celebration event. • The tamariki/rangatahi must attend one other activity session per week or as agreed during the first 12 week programme and 2 activity sessions thereafter. To Refer - Please complete the form on the reverse and give as much information as possible and ensure that the parent/carer/whanau reads and signs the parental consent form. Completed forms should be returned to: referrals@ranginui.co.nz
T.T.A REFERRAL FORM Person Being Referred Surname: ……………………………………………… First name(s): ……………………………………………………. Address: ………………………………………………………………………………………………………………………….. ……………………………………………………………………………………………….. Post code: …………………….. Date of Birth: ………………………………. Gender: ……………............. Ethnicity: ……………………………… Disability YES/NO Nature of disability: ………………………………………………………………………………… Contact Name and Phone: (for arranging appointment) ……………………………………………………………………………………………………………………………………..... Weight information - please provide all known information (at least height and weight) Position on Growth Chart (must be BMI >28+): …………………………………….. Height: …………………….. Weight: …………………….. BMI: …………………….. Medical History - please give details of any relevant medical conditions including any that may have an effect on the individual’s weight or their ability to follow a healthy eating plan (e.g. past history of eating disorder or a condition that impacts on appetite) or any condition which may impact on their participation in physical activity. ……………………………………………………………………………………………………………………………………..… ……………………………………………………………………………………………………………………………………..… Current medication: ……………………………………………………………………………………………………………
Referrer’s Information Referrer Name: …………………………………………………………………………………………………………………. Relationship: …………………………………………………………………………………………………………………….. Organisation: …………………………………………………………………………………………............................... Phone: ……………………………………………….. Email: ………………………………………………………………... Date……………………………….. Signature: ……………………………………………………………………………….
Parental Consent I agree to my tamariki/rangatahi being referred to the Te Tūāpapa Auaha programme and to the transfer of the personal & medical information given on this form. By signing this declaration I am consenting to Te Tūāpapa Auaha using the information on this form for the purpose of service management. If you have any queries concerning data protection please contact: referrals@ranginui.co.nz Parent/Caregiver Name (block capitals)…………………………………………………….................................. Signature ………………………………………………………………..
Date: ……………………………………………