STR Referral Form

STR Referral Form

STR 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.
- REFERRER INFORMATION
- Name of person making referral*
  
  First NameLast Name
- Relationship to participant*
- Mobile Number*
  Format: (0000) 000-000.
- Referrer Email*
- SCREENING QUESTIONS
- Do you live alone?*
  
  YesNo
- Do you live in SIL Accommodation?*
  
  YesNo
- What is the purpose for your STR?*
  
  0/30
- PARTICIPANT INFORMATION
- Participant Full Name*
  
  First NameLast Name
- Participant Email*
- Gender/ Pronoun*
- Date Of Birth*
  
  DayMonthYear
- Participant Mobile Number*
  Format: (0000) 000-000.
- Address*
  
  Street Address
  
  Street Address Line 2
  
  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*
- PARENT/ NOMINEE INFORMATION
- Parent/ Nominee Full Name
  
  First NameLast Name
- Parent/Nominee Mobile Number
  Format: (0000) 000-000.
- Parent/Nominee Email
- OR
- Emergency Contact Name
  
  First NameLast Name
- Emergency Email
- Emergency Mobile Phone Number
  Format: (000) 000-0000.
- PLAN INFORMATION
- 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 of who will sign the Service Agreement*
  
  First NameLast Name
- Email of who will sign the Service Agreement*
- SUPPORT NEEDS
- Name/ Email of your support coordinator (if applicable)
  
  First NameLast Name
- 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
- PREFERENCE & CONSENT
- Please note that we require a three-week notice period to adequately plan your stay.
  
  For urgent or emergency short-term accommodation (STR) requests, please contact us directly at 08 6205 4848 to check availability. We will make every effort to assist you whenever possible.
- Please advise of any mentor preferences, or just put N/A*
  
  0/30
- Preferred dates of STR*
- Preferred location(s) of STR*
- 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 STR, which are not shared on social media? At the end of STR, 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
- UPLOAD DOCUMENTS
  
  Such As NDIS Plan And Provider Reports
- Upload documents here, such As NDIS Plan And Provider Reports
  
  Cancelof
- Should be Empty: