School Holidays Program – Little Barista Little Barista Referral Form Program Date My Child is not an NDIS ParticipantMy Child is not an NDIS Participant Participant Details First Name* Last Name* Date of Birth* Phone Number* Email* Gender Street Address Suburb State Postcode Participant Representative Details (If applicable) First Name Last Name Representative Role Phone Number Email NDIS Details (If applicable) Plan Plan Manager NDIS Number Plan Start Date Plan End Date Primary Diagnosis Participant Goals (As stated in NDIS plan) Referrer Details First Name Last Name Organisation Name Phone Number Email I have obtained consent from the participant to make this referral and provide Soaring Together with the participant's personal and medical details. Risk & Support Information Please provide details regarding any known risks Will the person need 1:1 support to successfully complete the program? YesNo Please provide details Can the participant safely handle and manipulate small objects? YesNo Please provide details Are they aware of risks with hot equipment? YesNo Please provide details Any difficulty with hand/arm movements? YesNo Please provide details Participant response to noisy environment Can the participant follow simple written instructions? YesNo Please provide details Communication Preferences Can the participant record simple information? YesNo Please provide details Comfort with basic numbers Can the participant engage in small group activities? YesNo Please provide details Interaction with new people Do they require prompting? YesNo Please provide details Additional Information How did you hear about us? Any additional information Please leave this field empty. Δ
