Referral Form – Little Lantern Group

Referral Form

Details of the person requiring NDIS support

Surname

Given Name(s)

Preferred Name:

Date of Birth

Sex :

Male Female Intersex or Indeterminate

Residential Address Details

Postal Address Details

Email address

NDIS Number

Home Phone No

Mobile No

Preferred Language/Dialect

Interpreter Required?

Yes No

Copy of NDIS Plan Provided:

Yes No

Disability (if known)

Are there any requirements we should be aware of

Reason for referral

Primary carer/next of kin/Advocate/ Guardian details (if required)

Full name

Relationship to person

Postal Address

Email address

Home Phone No:

Mobile No

Referrer details

Full name

Organisation

Position title

Contact No

Postal Address

Email address

Date

We walk beside families, carers, and communities with respect and care — offering NDIS support, child and youth protection services, and healing pathways grounded in culture, dignity, and trust.

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Acknowledgement of Country

Little Lantern Group acknowledges the Traditional Custodians of the lands on which we operate. We pay our respects to Elders past, present, and emerging, and honour their enduring connection to Country, culture, and community.

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Acknowledgement of Country