Peer Mentor Referral Form CommentsThis field is for validation purposes and should be left unchanged.Participant First Name(Required)Participant Surname(Required)Preferred Pronouns(Required)... selectshe/her/hershe/him/histhey/them/theirsParticipant Preferred NameIf applicableParticipant Phone NumberIf applicableParticipant Email AddressIf applicableDisability(Required)NDIS Number(Required)Gender(Required)... selectFEMALEMALENON-BINARYTRANSGENDEROTHERPrefer not to sayDate of Birth(Required) DD slash MM slash YYYY English speaking(Required)YESNOMain Language (if not English)Address Line 1(Required)Address Line 2Suburb(Required)State(Required)... selectACTNSWNTQLDSATASVICWAPostcodePrimary Contact DetailsIs The Participant The Primary Contact?(Required) Yes, Participant is the Primary Contact No, Participant is not the Primary Contact Primary Contact NamePrimary Contact RelationshipPrimary Contact Email AddressPrimary Contact Phone NumberNDIS Plan & Funding DetailsNDIS Plan Start Date(Required) DD slash MM slash YYYY NDIS Plan End Date(Required) DD slash MM slash YYYY PACE Plan or PRODA Plan?(Required)... selectPACE PlanPRODA PlanNot sureHow is your NDIS Plan managed?(Required)... selectSelf-ManagedPlan-ManagedNDIA-ManagedPlan Manager NamePlan Manager Phone NumberPlan Manager Email AddressDo you have a Support Coordinator?(Required)... selectYesNoI am the Support CoordinatorNo, but I have funding for a Support CoordinatorSupport Coordinator NameSupport Coordinator Phone NumberSupport Coordinator Email AddressSupport Coordinator OrganisationFunding Budgets for Peer MentoringFunding Budget for Peer Mentor Support(Required) Core 01 - Assistance with Daily Life Core 04 - Access Community, Social And Rec Activities Capacity Building 09 - Increased Social and Community Participation Capacity Building 10 - Finding and Keeping a Job Capacity Building 11 - Improved Relationships Capacity Building 15 - Improved Daily Living I am unsure & need assistance navigating my funding Allocation for Peer Mentoring ($) - Core 01(Required)Hours for SupportAllocation for Peer Mentoring ($) - Core 04(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 09(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 10(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 11(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 15(Required)Hours for SupportTotal Allocation for Peer MentoringNDIS Goals (include what you want to get out of your Peer Mentor Supports)(Required)Interests & Hobbies(Required)Peer Mentor Session DetailsPreferred Gender(Required)... selectFEMALEMALENO PREFERENCESession Timeslot(Required)... selectBEFORE SCHOOLAFTER SCHOOLDURING SCHOOL HOURSWEEKENDSPreferred Day, Times & Frequency (e.g., Mondays weekly from 3pm to 6pm etc.)Shift Pick Up Location (Home, School, Other Address)Medical Conditions / Allergies / Intelorances(Required)Challenges / Triggers / Fears / Risks(Required)Travel Considerations(Required)Current Living Circumstances(Required)Additional InformationEmergency Contact same as Primary Contact... selectYESNOEmergency Contact NameEmergency Contact RelationshipEmail AddressPhone NumberDo you have a Behaviour Support Practitioner (BSP)?(Required)... selectYesNoI am the Behaviour Support PractitionerNo, but I have funding for a Behaviour Support PractitionerBSP NameBSP Phone NumberBSP Email AddressBSP OrganisationRelevant Attachments (optional) For example: NDIS Plans, Therapy Reports, Behaviour Support Plans, Medical Treatment Plans if you have consent to share these with EPS. This is not mandatory to include when submitting a referral Drop files here or Select files Accepted file types: jpg, png, pdf, docx, Max. file size: 50 MB. Who is making this referral?(Required) 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 Email(Required)Referrer's Phone(Required)Referrer's Organisation (If Applicable)Have You Referred To Us Before?(Required) 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.
