Client Referral Form

Young Leaders Youth Services (YLYS) is a community-based, mobile service delivering mentoring and disability supports across Sydney, the Illawarra, and the Nepean region, with planned expansion into Newcastle, Canberra, Melbourne, and Queensland.

We provide inclusive, person-centred supports to children, young people, and young adults aged 7–30 across the NDIS, Out-of-Home Care (OOHC), and the broader community. Our services are designed to promote independence, build life skills, and strengthen meaningful connections within the community.

This referral form can be completed by a participant’s parent, guardian, foster carer, caseworker, support coordinator, or relevant professional. Participants aged 18 years and over who are self-managed or plan-managed under the NDIS may also complete the form independently.

Once the referral is submitted, a member of our team will be in contact to discuss supports, goals, and next steps to ensure services are tailored to the participant’s individual needs.

Participant Details

Participants Full Name: *

Date of Birth: *

Participants Address: *If you prefer not to share the full address, that’s completely fine, please just provide the suburb and state.

Living Arrangement *

Living at Home (Family/Guardians)Foster Care OOHC (Residential Care, Intensive Therapeutic Care (ITC), Emergency / Short-Term Care)Supported Independent Living (SIL) Transitional Supported Independent Living (TSIL)Other (Please Specify)

NDIS Number:

NDIS Plan Start Date:

NDIS Plan End Date:

Diagnosis:Please outline any relevant diagnoses (e.g., ASD, ADHD, intellectual disability, mental health conditions, etc.)

Referral Information

Reason for Referral:Please outline the purpose of the referral (e.g., behavioural support, social skill development, community engagement, building independence, etc.)

Other (please specify):

Service Required

We provide mentoring and disability support services across Sydney, the Illawarra, and the Nepean regions. As a mobile service, we deliver supports directly within the community, home, or preferred environment to best meet the participant’s needs.

We accept referrals for participants funded through the NDIS, young people in Out of Home Care (OOHC), and individuals accessing supports through community or private arrangements. Access to our services is not limited to NDIS funding. For OOHC referrals, supports can be facilitated through labour hire in partnership with the referring organisation and the Department of Communities and Justice (DCJ). We also support families, carers, and guardians through private funding options where required.

We welcome referrals from support coordinators, caseworkers, schools, and community organisations, and can tailor programs and workshops to suit the individual needs, goals, and circumstances of each participant.

Please select the services required: *

NDIS-Funded SupportOut-of-Home Care (OOHC) SupportCommunity-Based SupportPrivately Funded Support

Comment

Referrer Details:

Full Name: *

Relationship to the participant named above: *

Organisation (if applicable):

Support Coordinator (if relevant):

If the participant has an NDIS Plan Manager, please provide their details:If the participant has a Plan Manager, please provide their details, including organisation name, email, and contact number.

Phone *

Email Address *

How did you find Young Leaders Youth Services?This helps us understand how we’re reaching the community.

Where did you hear about us?

Signature *

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If you are unable to sign on a device, please type your name or initials instead (optional).