Participant Referral Form

  • PARTICIPANT REFERRAL FORM

  • Please use our updated referral form here: Mighty Mentors: Referral Form

    This version will be discontinued shortly.

  • REFERRER INFO

  • 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 (08) 6205 4848 to discuss your specific requirements — we're here to help find the best possible match for your needs.

    • 1. Referrer Details 

    • REFERRER DETAILS

    • Format: (0000) 000-000.
    • 2. Participant Details 

    • PARTICIPANT DETAILS

    • Participant Date Of Birth*
       - -
    • 3. Nominee/ Guardian Info 

    • NOMINEE/ GUARDIAN INFO

    • Format: (0000) 000-000.
    • 4. Plan Details 

    • PLAN DETAILS

    • NDIS Plan Start Date*
       - -
    • NDIS Plan End Date*
       - -
    • 5. Funding Information 

    • FUNDING INFORMATION

    • 6. Contact Details  

    • CONTACT INFORMATION

    • Format: (0000) 000-000.
    • Format: (000) 000-0000.
    • Until
    • 7. Support Needs 

    • SUPPORT NEEDS

    • 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.

    • Rows
    • Are you wanting support on Public Holidays?*
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    • 0/35
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    • 8. Social Media Consent 

    • SOCIAL MEDIA CONSENT

    • 9. Photo Upload 

    • PHOTO OF YOU (PARTICIPANT)

    • Browse Files
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    • 10. NDIS Goals 

    • NDIS GOALS

    • 0/40
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    • 11. Document Uploads 

    • Please upload a copy of any other documents

      Allied Health assessments or reports
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    • Today's date and time
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