Participant Referral Form

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 SupportIndividualised living options
Please note, Mighty Mentors has a 4 hour minimum shift per week policy. Thank you for understanding.

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

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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: