Peer Mentor Referral Form Printable Version Here EmailThis 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 applicableDiagnosis / Disability(Required)NDIS Number(Required)Gender(Required)... selectFEMALEMALENON-BINARYTRANSGENDEROTHERPrefer not to sayDate of Birth(Required) English speaking(Required)YESNODo you require a language interpreter?(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 Name(Required)Primary Contact Relationship(Required)Primary Contact Email Address(Required)Primary Contact Phone Number(Required)Preferred Contact Method Phone Text Email No Preference NDIS Plan & Funding DetailsNDIS Plan Start Date(Required) NDIS Plan End Date(Required) 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)Please note these allocations are calculated at weekday rates and exclude kilometres and supports delivered outside normal hours. Hourly rates will vary if support is delivered in Evenings (after 8pm), Saturdays, Sundays & Public Holidays. 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 01Hours for SupportAllocation for Peer Mentoring ($) - Core 04(Required)Hours for SupportAllocation for Peer Mentoring ($) - Core 04Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 09(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 09Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 10(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 10Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 11(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 11Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 15(Required)Hours for SupportAllocation for Peer Mentoring ($) - Capacity Building 15Hours for SupportTotal Allocation for Peer MentoringNDIS Goals(Required)Include what you want to get out of your Peer Mentor SupportsInterests & Hobbies(Required)Peer Mentor Session DetailsPreferred Gender(Required)... selectFEMALEMALENO PREFERENCESession Timeslot(Required)... selectBEFORE SCHOOLAFTER SCHOOLDURING SCHOOL HOURSWEEKENDSPreferred Day, Times & FrequencyE.g., Mondays weekly from 3pm to 6pmShift Pick Up LocationHome, School, Other AddressParticipant SchoolIf applicableTravel Considerations(Required) YES NO Provide details of any travel considerationsMedical Conditions(Required) YES NO Provide details of medical conditionsAllergies(Required) YES NO Provide details of allergiesChallenges / Triggers / Fears / Risks(Required)Current Living Circumstances(Required)Additional InformationEmergency Contact same as Primary Contact... selectYESNOEmergency Contact Name(Required)Emergency Contact Relationship(Required)Email Address(Required)Phone Number(Required)Do you have a Behaviour Support Practitioner (BSP)?(Required)... selectYesNoI am the Behaviour Support PractitionerNo, but I have funding for a Behaviour Support PractitionerBSP Name(Required)BSP Phone Number(Required)BSP Email Address(Required)BSP Organisation(Required)Relevant 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 Word of Mouth Google Social Media Radio Care Team Member Other Please SpecifyReferrer's DetailsReferrer's Name(Required)Referrer's Email(Required)Referrer's Phone(Required)Referrer's OrganisationHave 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 Word of Mouth Google Social Media Radio Care Team Member Other Please SpecifyThank you for thinking of EPS again! We truly appreciate your continued support and trust in our team here at EPS.
