STR Referral Form
  • STR REFERRAL FORM

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

    This version will be discontinued shortly.

    • 1. Referrer Information 
    • REFERRER INFORMATION

    • Format: (0000) 000-000.
    • 2. Screening Questions 
    • SCREENING QUESTIONS

    • Do you live alone?*
    • Do you live in SIL Accommodation?*
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    • 3. Participant Information 
    • PARTICIPANT INFORMATION

    • Date Of Birth*
       - -
    • Format: (0000) 000-000.
    • Are you an existing participant with Mighty Mentors?*
    • Do You Have A Companion Card?*
    • Do you have a Concession Card?*
    • 4. Parent/ Nominee Information 
    • PARENT/ NOMINEE INFORMATION

    • Format: (0000) 000-000.
    • OR

    • Format: (000) 000-0000.
    • 5. Plan Information 
    • PLAN INFORMATION

    • NDIS Plan Start Date*
       - -
    • NDIS Plan End Date*
       - -
    • Management Type*
    • 6. Support Needs 
    • SUPPORT NEEDS

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    • Are you a wheelchair user?*
    • 0/30
    • 0/30
    • 0/30
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    • 7. Preferences & Consent 
    • 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.

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    • 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?*
    • 8. Upload Documents Here 
    • UPLOAD DOCUMENTS

      Such As NDIS Plan And Provider Reports
    • Browse Files
      Drag and drop files here
      Choose a file
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