Groups Referral Form
Name of Person Filling out Form
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Identity of Person Filling out Form
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Self
Guardian
Parent
Support Worker
Support Facilitator
Support Coordinator
OTHER
Participant Details
First Name
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Last Name
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Phone Number
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Have you participated in Groups at Real Life Assistants before?
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Yes
No
NDIS Number
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Phone Number
Email Address:
Plan Start Date
Plan End Date
Does the participant have a Support Coordinator?
Yes
No
Support Coordinator
Support Coordinator Name
Support Coordinator Contact Number
Support Coordinator Email
How is the plan funded?
Plan Managed
Self Managed
Agency Managed
Plan Manager
Plan Manager Name
Plan Manager Contact Number
Plan Manager Email Address
Self Managed
Who to send Invoices to (if different than Participant name)
Email address to send Invoices to (if different than Participant email)
Group Details
What Groups are you interested in?
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Footy Fanatics (18+) Fridays (6pm-11pm)
RLA 4 Kids (9-13) Mondays (School end – 6pm)
Lego Group (9-13) Tuesday (3:30pm – 6pm)
Board Games (18+) Wednesday (1pm -4pm)
Crafternoon Tea (18+) Tuesday (1pm – 4pm)
Board Games for Teens (14-18) Wednesday (4pm – 8pm)
Dungeons & Dragons (18+) Various (3pm-8pm)
Girls Night Out (18+) ONCE A MONTH, Various (6pm-11pm)
Photography (18+) Thursdays (9 am - 2 pm)
Whale Watching (18+) Times and Days TBA (5 hours a week)
Do you require transport assistance?
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Yes
No
The majority of the Groups listed above do not include transport time.
Transport Assistance details
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Feedback
How did you hear about us?
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Website / Web Searching
Facebook / Social Media
LAC
Plan Manager
Support Coordinator
Word of Mouth
Other
How did you hear about us? (Other)
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Do you have any feedback about our referral form?
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