Covid19 Declaration

Tēnā Koe
In line with New Zealand’s Ministry of Health guidelines and Taranaki Retreat's commitment to providing a safe support environment, we ask you, please, to answer the following questions, to help us to know how best to support you.

Everyone accessing support from us should complete this form or, if they are minors, have the form completed on their behalf. If you have concerns or questions about completing the form, please do not hesitate to reach out to us, here. THANK YOU!

Covid 19 Confidential Declaration

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Have you or anyone you immediately know had a confirmed case of COVID-19? *

Yes No

If Yes, please tell us more, here *

Have you been to a country or area of concern with COVID-19 in 2020? *

Yes No

If Yes, please tell us more, here *

Please click here for the current list of countries or areas of concern.

Have you or anyone you immediately know travelled nationally (out of your region) or internationally in the last month? *

Yes No

If Yes, please tell us more, here *

Do you, or anyone within your home/whānau, currently have any of the symptoms associated with Covid-19? *

Yes No

If Yes, please tell us more, here *

Are you completing this form on behalf of any children or teenagers? Please either enter "No", or otherwise, tell us their names. *

Please enter here any further information which may be relevant - for example, underlying health concerns which may place you at a higher risk - otherwise, please enter N/A *

Please click 'Send' to complete this process. By doing so, you confirm that all the information shared here to be true and correct. We will not share this information more widely without your consent, unless we are required to do so for contract tracing - in which case, we will keep you informed of that process. Kia ora ra - we are here for you - no matter what the answers you provide here.

Send

Taranaki Retreat Covid 19 Declaration Form

Covid 19 Confidential Declaration