Supports and Referral Request - The Mai-Wel Group

Mai-Wel Supports and Referral Form

Please complete the form below as best you can to ensure we have as much information as possible to best support you.
If you wish to discuss the information in this form further, please contact our Supports, Transition and Referral Team on 4057 2900 or email start@maiwel.com.au

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender *

Please specify *

Street Address *

Postal Address *

Living Arrangement *

Phone number 1 *

Phone number 2

Email Address *

Cultural

Country of Birth *

Religion *

Are there any Religious or cultural practices that you would like us to know about? *

Yes

Do you identify as Aboriginal or Torres Strait Islander? *

Please provide details of Religious or cultural practices that you would like us to know about *

Languages spoken *

Is an interpreter required? *

Yes

Participant NDIS Plan Details

NDIS Number *

How is your NDIS funding managed? (Please select more than one option if plan is managed in multiple ways) *

Agency Managed

Plan Managed

Self Managed

Plan Manager Name *

Plan Manager Email Address *

Plan Manager Address *

Plan Manager Phone Number *

Self Management Contact Name *

Self Management Contact Email Address *

Self Management Contact Address *

Self Management Contact Phone *

Are you currently on the NDIS Portal or Pace Portal? *

NDIS Portal

Pace Portal

Not sure

Do you have a Support Coordinator? *

Yes

Do you work with a Mai-Wel Support Coordinator or external provider Support Coordinator? *

Yes

Support Coordinator Name *

Support Coordinator Address *

Support Coordinator Email Address *

Support Coordinator Phone *

Do you have a support person for decisions or a NDIS nominee contact? *

Yes

Support Person or NDIS Nominee Name *

Support Person or NDIS Nominee Address *

Support Person or NDIS Nominee Phone number *

Support Person or NDIS Nominee Email Address *

Relationship to Support Person or NDIS Nominee *

How will in service activity-based kilometres be covered? *

Financial Contact Name (Who can the Mai-Wel Accounts Team talk to about financial transactions for activity-based fees or kilometres which are being invoiced directly to the participant?)) *

Financial Contact Address *

Financial Contact Email Address

Financial Contact Phone *

Participant Support Details

Tell us about yourself, your goals and interests *

What support services are you interested in with Mai-Wel? *

Employment Pathways

Home and Living Pathways

Social, Community and Creative Pathways

Support Coordination

Which Employment Pathways supports are you interested in? *

Employment Preparation

Supported Employment

Open Employment/DES Referral

What type of employment are you interested in? (Please include hours or work, field of interest, long term goals and other relevant details.) *

How will you be transported to and from supports? *

Contacts

Name *

Relationship *

Address *

Phone number *

Email Address *

Do you have a Contact 2? *

Yes

Name *

Relationship *

Address *

Phone number *

Email Address *

Do you have a Contact 3? *

Yes

Name *

Relationship *

Address *

Phone number *

Email Address *

School

Do you currently attend school? *

Yes

School Name *

Name of preferred contact person at school *

School Address *

School Phone *

School Email Address *

Legal and Guardianship

Are there any caseworkers relating to you? (Under 18 only) *

Yes

Please provide caseworker contact details *

Is there a custody arrangement in place? (Under 18 only) *

Yes

Please provide custody arrangement details *

Are there any Guardianship, Power of Attorney or Trustee orders in place? *

Yes

Please provide Guardianship, Power of Attorney or Trustee details *

Attach copy of Guardianship/Care Orders

Choose File

Do you control your own finances/money? *

Yes

Next Steps

The next step of your intake journey with Mai-Wel is to meet with the Intake Panel. A member of the Mai-Wel team will contact you within 3 working days to advise of your Intake Meeting date, time and location. It would be great if this meeting could be face to face at a Mai-Wel site. If this isn’t possible we can hold a virtual meeting via Microsoft Teams. You are welcome to bring family, friends or other supporters to your Intake Meeting, please let the team know when they call who will be attending with you.

When attending your Intake Meeting, please bring along any care plans, reports, medication details etc that Mai-Wel will need to know about to ensure you receive safe and individualised supports. This information will be used to inform and train your support team, and will be included on your electronic file for your support team to access during your supports. It is important that you provide this information so we can keep you and others safe, and ensure you reach your goals.

Mai-Wel takes it’s responsibility to keep your personal information private and secure very seriously, and you can ask for further information on how this occurs.

By submitting this contact form I accept that my contact details provided will be used by Mai-Wel to respond to my enquiry. *

*I accept

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Mai-Wel Supports and Referral Form

Cultural

Participant NDIS Plan Details

Participant Support Details

Contacts

School

Legal and Guardianship

Next Steps

Title

Our Locations

John Street (formerly known as The Hill), Telarah

Creative Arts Studio, Maitland

The Cottage, Telarah

Mai-Wel Enterprises, Telarah

Mai-Wel Cessnock

Mai-Wel LabourForce Solutions, Cessnock

Mai-Wel LabourForce Solutions, Maitland

Mai-Wel LabourForce Solutions, Dungog

Mai-Wel LabourForce Solutions, Singleton

Mai-Wel LabourForce Solutions, Kurri Kurri

Mai-Wel Corporate Services, Maitland

Our Services

Fundraising & Donations

Careers

About Mai-Wel

The Mai-Wel Group acknowledges the Traditional Custodians of the land on which we live, work and learn. We pay our respects to Elders past, present and future, and recognise their continuing connection and contribution to the land.