Q1. You want which?

Face to face share story abuse in care?
Face to face help write story abuse in care?

Support find records from:

Van Asch School
Kelston Deaf Education Center
Social Welfare
Mental Hospital

Q2. Name

Q3. Date of Birth

Q4. Race / Iwi

Māori
Pākehā / NZ European
Asian
Pasifika
Indian
Other

Q5. Email Address

Why need Email?

Q6. Deaf Contact

Deaf to Deaf
Nikki

Q7. Contact How?

Messenger
Whats App
Zoom
Skype
Teams meeting

Q8. Hearing Person Contact?

Yes
No

Q9. Contact How?

NZ Relay (Phone interpreter)
Interpreter Service
Connect
ISign
WordsWorth

Q10. Interpreter Name

Interpreter number Contact

Q11. Email contact in English?

Yes
No

Q12. Email contact in Sign?

Yes
No

Q13. Health problems have?

Yes
No

Q14. Health problem what?

Wheelchair user
Epilepsy
Cerebral Palsy
Brain Injury
Other

Q15. Mental Health Issue Have?

Yes
No

Q16. Mental health Problem what?

Bipolar
Depression
Anxiety
Trauma / PTSD
Other
Don't know

Q17. Mental health Support have what?

Medication
Support Person
Psychiatrist

Q18. See SES - you comfortable where?

Private room Deaf Club
Motel Room
Own Home
Marae
Zoom
Other

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