Peer Mentor Referral Form

Participant first name(Required)

Participant surname(Required)

Prefered pronouns(Required)

Participant preferred name

Participant phone

Participant email

Disability(Required)

NDIS number(Required)

Gender(Required)

Date of birth(Required)

English speaking(Required)

Main language (if not English)

Address line 1(Required)

Address line 2

Suburb(Required)

State(Required)

Postcode

Primary Contact Details

Is The Participant The Primary Contact?(Required)

Yes, The Participant Is The Primary Contact

No The Participant Is Not The Primary Contact

Name

Relationship

Phone

NDIS Plan Details

NDIS Plan Start Date(Required)

Plan End Date(Required)

How is your Plan managed?(Required)

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)(Required)

Interests & Hobbies(Required)

Peer Mentor Session Details

Preferred Gender(Required)

Session Timeslot(Required)

Preferred Day & Times (e.g. Mondays 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 Information

Emergency Contact same as Primary Contact

Relevant Attachments (optional)

Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 50 MB.

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

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 Details

Referrer'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.

Name

This field is for validation purposes and should be left unchanged.