Peer Mentor Referral Form Participant first name(Required) Participant surname(Required) Prefered pronouns... selectshe/her/hershe/him/histhey/them/theirsParticipant preferred name Participant phone Participant email Disability NDIS number Gender... selectFEMALEMALENON-BINARYTRANSGENDEROTHERPrefer not to sayDate of birth DD slash MM slash YYYY English speakingYESNOMain language (if not English) Address line 1 Address line 2 Suburb State... selectACTNSWNTQLDSATASVICWAPostcode Primary Contact DetailsName Relationship Email Phone NDIS Plan DetailsNDIS Plan from Date DD slash MM slash YYYY Plan to Date DD slash MM slash YYYY How is your Plan managed?... selectSelf-ManagedPlan-ManagedNDIA-ManagedIf Plan Managed, please provide Plan Manager's details.Plan Manager Name Plan Manager Phone Number Plan Manager Email Address NDIS Goals (include what you want to get out of your Peer Mentor Supports)Interests & HobbiesPeer Mentor Session DetailsPreferred Gender(Required)... selectFEMALEMALENO PREFERENCESession Timeslot(Required)... selectBEFORE SCHOOLAFTER SCHOOLDURING SCHOOL HOURSWEEKENDSPreferred Day & Times (e.g. Mondays 3pm to 6pm etc) Medical Conditions / Allergies / IntelorancesChallenges / Triggers / Fears / RisksTravel ConsiderationsCurrent Living CircumstancesAdditional InformationEmergency Contact same as Primary Contact... selectYESNOReferrer's DetailsReferrer's Name(Required) Referrer's Email Referrer's Phone(Required) Referrer's Organisation (If Applicable) Relevant Attachments (optional) Drop files here or Select files Accepted file types: jpg, png, pdf, docx, Max. file size: 50 MB. For example: NDIS plans, therapy reports, medical treatments plans if you have consent to share these with EPS. This is not mandatory to include when submitting a referralPhoneThis field is for validation purposes and should be left unchanged.
