Mataatua Heru & Hapū Māmā 2022 Registration Form

MATAATUA HERU & HAPŪ MĀMĀ 2022 REGISTRATION

Nau mai, haere mai ki te kaupapa o Heru & Hapū Māmā. We would like to welcome you to this special space in support of offering a kaupapa māori maternal wellbeing program. We are honored to walk alongside you on your journey of oranga. We require a few details to get started so lets get into it.

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* 1. What is your name?

Name

Date of birth

Current address

City/Town

Postal code

Iwi

Hapu

Email Address

Phone Number

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* 2. (estimated) How many weeks pregnant are you?

1 - 17 weeks

18 - 28 weeks

29 - 40 weeks

Unsure

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* 3. How many pregnancies have you had? including loss

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* 4. Do you currently have a midwife?

Yes

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* 5. How long have you smoked for?

Under a year

Over a year

Over 5 years

over 10 years

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* 6. Have you ever tried to quit smoking before?

Yes

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* 7. What are two key motivators for you to quit smoking and have a healthier pregnancy? (no judgement)

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* 8. How would you rate your personal knowledge of the māori culture? eg: stories, tikanga, te reo, waiata, karakia etc

None - Very little knowledge

Comfortable - Medium level of knowledge

Confident - Expert level of knowledge

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* 9. Do you own a mobile phone or device?

Yes

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* 10. Do you have access to decent internet at least once a week?

Yes

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* 11. Do you currently have any knowledge around the Heru?

Yes

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* 12. Are you able to commit to the 6 week program?

Yes

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* 13. Please choose the most useful topic below that you feel would support you the most in your journey of remaining smoke free and achieving your goal of wellbeing during the program?

Matauranga Maori - Traditional practices, Art, Taonga, Purakau, Rongoa

Birth Education - Stages of labor, medical interventions, anatomy

The harms of smoking & Cessation education - Nicotine Replacement Therapy education, tips and tricks to support

Testimonies from those who have been through the Heru & Hapu Mama program?

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* 14. How did you hear about the Heru & Hapu Mama Program?

Social Media

Whanau/Friend

Local Service Provider

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* 15. I give full consent to KAIRUA to use my data and any footage and materials to in support of the research of the Heru & Hapu Mama program. I am aware by selecting Yes it is received as my digital signature of approval.

Yes