STR Referral Form

STR REFERRAL FORM
Please use our updated referral form here: Mighty Mentors: Referral Form

This version will be discontinued shortly.
- 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?
- Do you live in SIL Accommodation?
- 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?
- Do You Have A Companion Card?
- Companion Card Number
- Do you have a Concession Card?
- 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
- 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?
- 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?
- 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.
- How Did You Hear About Us?
- UPLOAD DOCUMENTS
  
  Such As NDIS Plan And Provider Reports
- Upload documents here, such As NDIS Plan And Provider Reports
  
  Cancelof
- Should be Empty:

STR REFERRAL FORM

REFERRER INFORMATION

SCREENING QUESTIONS

PARTICIPANT INFORMATION

PARENT/ NOMINEE INFORMATION

PLAN INFORMATION

SUPPORT NEEDS

PREFERENCE & CONSENT

UPLOAD DOCUMENTS