Peer Mentor Referral Form Participant first name(Required)Participant surname(Required)Prefered pronouns... selectshe/her/hershe/him/histhey/them/theirsParticipant preferred nameParticipant phoneParticipant emailDisabilityNDIS numberGender... selectFEMALEMALENON-BINARYTRANSGENDEROTHERPrefer not to sayDate of birth DD slash MM slash YYYY English speakingYESNOMain language (if not English)Address line 1Address line 2SuburbState... selectACTNSWNTQLDSATASVICWAPostcodePrimary Contact DetailsIs The Participant The Primary Contact? Yes, The Participant Is The Primary Contact No The Participant Is Not The Primary Contact NameRelationshipEmailPhoneNDIS 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-ManagedPlan Manager NamePlan Manager Phone NumberPlan Manager Email AddressNDIS 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)Shift Pick Up Location (Home, School, Other Address)Medical Conditions / Allergies / IntelorancesChallenges / Triggers / Fears / RisksTravel ConsiderationsCurrent Living CircumstancesAdditional InformationEmergency Contact same as Primary Contact... selectYESNOWho is making this referral? It's me, The Participant I am referring on behalf of a participant We’d love to know how you found out about us if you have a moment to share.Referrer's DetailsReferrer's Name(Required)Referrer's EmailReferrer's Phone(Required)Referrer's Organisation (If Applicable)Have You Referred To Us Before? Yes, I’ve referred before No, this is my first time We’d love to know how you found out about us if you have a moment to share.Thanks for referring again! We truly appreciate your continued support and trust in our team. 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 referralEmailThis field is for validation purposes and should be left unchanged.
