Peer Mentor Referral Form Please give as much detail as possible. Fields marked with a red asterisk are required fields. If you are not sure of anything, please call us on (03) 4222 7479. Participant DetailsParticipants name:* NDIS Number:* Plan Start Date* DD slash MM slash YYYY Plan End Date* DD slash MM slash YYYY Date of Birth* DD slash MM slash YYYY Country of Birth* Gender*please selectFemaleMaleNon-BinaryPrefer not to sayOR self-describe (Gender): Aboriginal or Torres Strait Islander:*please selectYesNoPrefer Not To SayAddress Participant Email (if applicable) Participant Phone (if applicable) Participant School (if applicable) Diagnosis / Disability* Goals (in brief)Special InterestsNominee / Emergency Contact DetailsPrimary Contact* Phone* Relationship to Participant* Email* Secondary Contact* Phone* Relationship to Participant* Peer Mentor Shift DetailsPreferred Mentor Gender*please selectMaleFemaleNo PreferrencePreferred shift day & time* 2nd Preference day & time Food Allergies / Intolerance / Special requirementsIdentifiable risks (triggers, fears, absconding, etc)Travel or Safety ConsiderationsCultural Needs*Living Arrangements*Medical Conditions*Any Additional InformationAny Additional InformationFunding informationHow is the Plan Managed?* Plan Managed Self-Managed Agency Managed Funding amount to be allocated:* Which budget will the funds will draw from?Core - Social and community participationCapacity building - Increased social and community participationCapacity building - Improved daily livingIf Plan-Managed or Self-Managed, please provide details:Name of Plan Manager Email PhoneReferrer's Name* Referrer's Email* Please upload a copy of the NDIS PlanAccepted file types: jpg, gif, png, pdf, Max. file size: 20 MB.NameThis field is for validation purposes and should be left unchanged.
