Referrals | Pathway Support Network

Please note: Pathway Support Network is not an NDIS registered provider. However, we welcome participants who are NDIS Plan Managed or Self Managed, as these participants are able to choose their own support providers. If you are unsure about your plan type, please check with your NDIS planner or Support Coordinator.

1 Referrer Details

First Name *

Last Name *

Organisation / Relationship

Phone Number *

Email Address *

2 Client Details

Client First Name *

Client Last Name *

Date of Birth

Gender Identity

Phone Number

Email Address

Home Address / Suburb

Emergency Contact Name & Number

3 NDIS & Funding Details

NDIS Plan Type *

Plan Managed Self Managed Not Applicable / Unsure

NDIS Participant Number

Plan Manager (if applicable)

Support Coordinator (if applicable)

Plan End Date (if known)

4 Support Needs

Primary Support Area/s Requested *

Social & Community Support (outings, activities, social connection) Mental Health Support (wellbeing check-ins, coping strategies, emotional support) Both of the above

How often is support needed?

Weekly Fortnightly Monthly Flexible / As needed

Preferred Days

Preferred Start Date

Background & Reason for Referral *

Goals & What Support Should Help Achieve

Any Known Risks, Triggers or Important Information

5 Consent & Declaration

I confirm the client has given consent for this referral * I understand Pathway Support Network is not an NDIS registered provider and accepts Plan Managed or Self Managed participants * I would like to receive a copy of this referral by email

Our team will be in touch within 2 business days to discuss next steps.

Referral Submitted

Thank you. A member of the Pathway Support Network team will be in touch within 2 business days to discuss next steps.