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


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

Participant NDIS Plan Details

How is your NDIS funding managed? (Please select more than one option if plan is managed in multiple ways) *
Are you currently on the NDIS Portal or Pace Portal? *
Do you have a Support Coordinator? *
Do you work with a Mai-Wel Support Coordinator or external provider Support Coordinator? *
Do you have a support person for decisions or a NDIS nominee contact? *

Participant Support Details

What support services are you interested in with Mai-Wel? *
Which Employment Pathways supports are you interested in? *


Contact 1 type *
Do you have a Contact 2? *
Contact 2 type *
Do you have a Contact 3? *
Contact 3 type *


Do you currently attend school? *

Legal and Guardianship

Are there any caseworkers relating to you? (Under 18 only) *
Is there a custody arrangement in place? (Under 18 only) *
Are there any Guardianship, Power of Attorney or Trustee orders in place? *
Do you control your own finances/money? *

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. *