STA Referral Form

STA REFERRAL FORM
Important information before you begin

1. Please 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. Due to new legislative requirements, we cannot support participants for STA/ respite support if you live alone or in a SIL living arrangement.

5. Once the STA referral form is received, one of our team members will be in touch to verify the information provided. Once confirmed, a quote and service agreement will be sent through for electronic signing. Once a Service Agreement is in place and expenses have been pre-paid for the STA, 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. Screening Questions
SCREENING QUESTIONS
Do you live alone?*

YesNo
Do you live in SIL Accommodation?*

YesNo
What is the purpose for your STA/ respite stay?*

3. 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

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

First NameLast Name
Phone
Email
OR
Emergency Contact Name

First NameLast Name
Emergency Email
Emergency Mobile Phone Number

5. 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/ Email of who will sign the Service Agreement*

6. Support Needs
SUPPORT NEEDS
Name/ 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

7. Preferences & Consent
PREFERENCE & CONSENT
Please advise of any mentor preferences*
Preferred dates of STA*
Preferred location(s) of STA*
Do you give consent to share photos and videos to social media and our website?*

YesNo
Are you happy to have photos taken on the STA, which are not shared on social media? At the end of camp, you will be provided with a digital photo album of your memories made.*

YesNo
How Did You Hear About Us?*

Social MediaWord of MouthSupport CoordinatorOther

8. Upload Documents Here
UPLOAD DOCUMENTS

Such As NDIS Plan And Provider Reports
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