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Referral Form

Flexible, person-centred services designed to meet you where you are — and help you get where you want to go.

Participant Details

Support Coordination and Psychosocial Recovery Coaching across Perth and regional WA. Participants, families and referrers are welcome. Submit the form below and we’ll respond within one business day. Prefer a quick conversation? Use Contact Us or call 0493 625 184.

First name*

Date of Birth

Day

Month

Year

Address

Contact Phone Number*

Email Address*

NDIS Participant Number

NDIS Plan Start Date

NDIS Plan End Date

NDIS Plan Management Type *

Self-Managed

Plan-Managed

NDIA-Managed

Primary Disability / Mental Health Condition *

Current Supports

Referrer Details (if applicable)

If someone other than the participant is making the referral, please complete the below. If you are completing this for yourself, please proceed to Service/Support Needs.

Relationship to Participant

Referrer Full Name

Organization/Agency

Role/Position

Referrer Contact Phone

Referrer Email

Service/Support Needs

Specify which ROS services are being requested and the reasons/needs for the referral.

Requested Services *

Psychosocial Recovery Coaching

Support Coordination

Support Work (Mentoring/Skill Building)

Therapeutic Group Program (e.g., “Fun with Dice” role-play therapy group)

Unsure/Other

If other, please specify

Reason for Referral / Participant Goals *

Urgency / Preferred Start

Additional Notes

Consent

Confirm consent and privacy acknowledgements before submission

I confirm that the participant (or their legal guardian) has given consent for this referral and for ROS to collect and use the provided information to offer services.

I acknowledge that the information in this form will be kept confidential and used in accordance with ROS’s privacy policy.

Name of Person Giving Consent *

Date of Consent *