Skill Building and Independence Programs Referral Form

REFERRAL FORM
Important information before you begin

1. Please ensure you select the correct ratio of support depending on your support needs. Understand that we have a duty of care to our participants and mentors and therefore we need to be fully informed of support needs in order to plan effectively.

2. Please ensure Behaviour Support Plans or Functional Capacity Assessments are attached to this form if applicable.

3. We are unable to support participants who are NDIA managed, or those who have restrictive practices in place, due to Mighty Mentors being an unregistered provider.

4. Once the "Skill Building and Independence Programs" referral form is received, one of our team members will be in touch to confirm attendance. Once confirmed, a Service Agreement will be sent through for signing. Once a Service Agreement is in place and expenses have been pre-paid for the camp, any cancellations will incur a 50% charge of the funding amount stipulated within the service agreement.

1. Referrer Info
REFERRER INFO
Name of person making referral*

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

2. Participant Info
PARTICIPANT INFO
Participant Full Name*

First NameLast Name
Email*
Gender/ Pronoun*
Date Of Birth*

DayMonthYear
Phone Number*
Address*

Street Address 1

CityState / Province

Postal / Zip Code
Are you an existing participant with Mighty Mentors?*

YesNo
Do You Have A Companion Card?*

YesNo
Companion Card Number
Do you have a Concession Card?*

YesNo
Concession Card Number

2. Parent/ Nominee Info
PARENT/ NOMINEE INFO
Parent/ Nominee Full Name

First NameLast Name
Phone
Email

3. Plan Information
PLAN INFO
NDIS Number*
NDIS Plan Start Date*

DayMonthYear
NDIS Plan End Date*

DayMonthYear
Email to send invoices*
Management Type*

Self ManagedPlan Managed
Budget to claim from*
Name and Email of person signing the service agreement*

4. Support Needs
SUPPORT NEEDS
Name and Email of your support coordinator (if applicable)
Please list your disability and associated support needs*

0/30
Are you a wheelchair user?*

YesNo
Do you have a behaviour support plan? If yes, please attach it to this form. *

0/30
Do you have any dietary requirements or allergies?*

0/30
Do you require support with prompting or administering your medication?*

0/30
Do you require any other specialised training?*

0/30
What Support Ratio do you require? If you require high physical support needs or behavioural support needs, please select 1:1 to ensure you are adequately supported.*

1:11:2

6. Upload Documents
UPLOAD DOCUMENTS

Such As NDIS Plan And Provider Reports
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