Participant Referral Form

PARTICIPANT REFERRAL FORM
Important information before you begin

Please note, we are a non-registered provider and therefore can only support NDIS participant's with self managed or plan managed funding. We are unable to support participant's with NDIA managed funding.

We are unable to implement any restrictive practices, as we do not report to the Quality and Safeguard Commission, due to being an unregistered provider.

Mighty Mentors implement a minimum of 4 hours per week, and a mimimum of 2 hours per shift. There may be some exceptions and therefore if you would like to speak with someone personally to confirm if the referral will be accepted prior to completing the form, please call us on 0413 910 091. Our mentoring services are for ongoing support only, and unfortunately do not provide ad hoc support or only school holiday support.

Thank you for your understanding.
Metro Area – Full Coverage
We offer full mentor coverage across the entire Perth metro area. If you're located within this region, simply fill out our Referral Form below and we can get started matching you with a mentor straight away.

Mandurah & Regional Areas – Limited Coverage
Please note that in the Mandurah area and other regional locations near the Perth metro, mentor availability is currently limited. In these cases, placement may take longer or require additional coordination. Please call us directly on 0413 910 091 to discuss your specific requirements — we're here to help find the best possible match for your needs.

1. Referrer Details
REFERRER INFO
Name of person completing this form*

First NameLast Name
Relationship to participant *
Email*
Phone Number*

2. Participant Details
PARTICIPANT INFO
Participant Name*

First NameSurname
Participant Email*
Participant Gender/Pronoun*
Participant Date Of Birth*

DayMonthYear
Participant Contact Number*
Participant Address*

Street Address 1

CityState / Province

Postal / Zip Code

2. Nominee/ Guardian Info
NOMINEE/ GUARDIAN INFO
Nominee Name

First NameLast Name
Phone Number
Email
Relationship to Participant
Does the participant have a public guardian?*
Public Guardian Name

First NameLast Name
Phone Number
Email

3. Plan Details
PLAN DETAILS
NDIS Number*
NDIS Plan Start Date*

DayMonthYear
NDIS Plan End Date*

DayMonthYear
Name of person signing the Service Agreement*

First NameLast Name
Email*
Relationship*

4. Funding Info
FUNDING INFO
Management Type*

Self ManagedPlan Managed
What budget would you like us to claim from?*
Name of person/ organisation to send invoices*
Email to send invoices *
Total funding allocated for support*

5. Contact Details
CONTACT INFO
First point of contact*
Full Name
Email *
Contact Number*
What is your preferred method of contact?*
Name Of Support Coordinator*
Email*
Contact Number*
Best person to assist with the developement of your support plan*
What is the best time for your coordinator to contact you?*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
Total 0.0
What frequency would you like your coordinator to check in with you regarding support?*

WeeklyFortnightlyMonthly

6. Support Needs
SUPPORT NEEDS
Purpose Of Referral*

In home skill buildingCommunity based mentoringEmployment Support
Mighty Mentors implement a minimum of 4 hours per week, and a mimimum of 2 hours per shift. There may be some exceptions and therefore if you would like to speak with someone personally to confirm if the referral will be accepted, please call us on 0431 937 688. Our services are for ongoing support only, and unfortunately do not provide ad hoc support or only school holiday support.

Support Days/Times Start-Finish*

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Times

Are you wanting support on Public Holidays?*

YesNo
Do You Have A Companion Card?*
Do you have a Concession Card?*
Please List Your Support Team*

0/40
Please List Support Needs*

0/40
Are you a wheelchair user?*

YesNo
Do you require support with medication? Please specify if you require prompting and/or medication administration.*

0/35
Are there any restrictive practices in place or a behaviour support plan? Please note that because we are an unregistered provider, we are not able to implement any restrictive practices. *

0/35
Are there any cultural or religious considerations that you would like us to know?*
Language spoken at home*
Please list your primary and any secondary disabilities*
Please list your mentor preferences*

0/40
Do your mentors require any specialised training to support you?*

0/40
When do you want to commence support?*

DayMonthYear
Would you like access to Shiftcare connect to view your roster?*

YesNo

8. Social Media Consent
SOCIAL MEDIA CONSENT
Consent To Mighty Mentors Sharing Images/ Videos To Our Website And/ Or Social Media?*

YesNo
How Did You Hear About Us?*

Word of mouthSocial MediaSupport CoordinatorOther

9. Photo
PHOTO OF YOU (PARTICIPANT)
Please upload a photo of you (participant) for your support plan and client profile. This photo will not be shared with anyone outside of our organisation.

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10. NDIS Goals
NDIS GOALS
Please write your NDIS goals below or upload a copy of your NDIS goals. Alternatively, you can upload a copy of your NDIS plan.

0/40
Upload your NDIS Plan or goals below

Cancelof

11. Document Uploads
Please upload a copy of any other documents

Allied Health assessments or reports
Please upload your behaviour support plan, functional capacity assessment or any other allied health reports that may be useful for us to have.

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Other Notes

0/40
Date

DayMonthYear
Hour MinutesAM/PM Option
Should be Empty:

PARTICIPANT REFERRAL FORM

REFERRER INFO

PARTICIPANT INFO

NOMINEE/ GUARDIAN INFO

PLAN DETAILS

FUNDING INFO

CONTACT INFO

SUPPORT NEEDS

SOCIAL MEDIA CONSENT

PHOTO OF YOU (PARTICIPANT)

NDIS GOALS

Please upload a copy of any other documents