Client Referral Form

We provide mentoring and disability support services to participants across Sydney, the Sutherland Shire and the Illawarra region, with further expansion into Canberra and Newcastle.

We support participants of all abilities aged 6–35 years, including children, young people and young adults across the disability sector, Out-of-Home Care (OOHC) sector, and privately funded supports.

Referrals can be made directly by participants over the age of 18, families, support coordinators, caseworkers, and other referring services, including schools, Police and community organisations.

Once a referral is received, a member of our team will be in touch to discuss the participant’s support needs and the next steps.

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

If you are referring a participant who is NDIS funded, please provide the relevant NDIS and funding details below.

If you are referring a participant who is not NDIS funded, including a young person in Out-of-Home Care (OOHC) or living at home with family, please provide details about the supports required in the comments section below.

Please select the services required: *

NDIS-Funded SupportOut of Home Care (OOHC) Funded 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).