Support Networks Individual Packages

Support Networks Individual Packages

This program includes individualisedfunding packages for a young person with a disability (18 – 25 years) and their families to use to implement their plan for establishing, building and maintaining social and support networks, and connectivity with their community.

Funding can be used to:

• Pay for enrolment fees for a young person (18 – 25 years) to join their local sporting team;
• Purchase equipment for the young person to join in activities in their local community;
• Access social and personal development group programs run through local youth services;
• Assistance with transport costs;
• Cover course fees for enrolling in educational course/personal development;
• Pay for staff to support the young person to access everyday community based activities alongside their peers (e.g. attending a concert, entertainment venues, football games);
• Purchase a Northcott facilitated partnership event/activity;
• Pay of gym membership, dance classes, music classes, and recreational activities.

Referrer Details

Name and position:

Agency:

Telephone:

Email:

Date of referral:

Does the young person consent for referral, including understanding that Support Networks may contact them for further details about this referral if required: □NO □ YES

Details of person with Disability

Name:

Gender:

Date of birth:

Address:

LGA:

Telephone:

Primary Disability:

Other Disability:

Aboriginal or Torres Strait Islander: □ABORIGINAL □TORRES STRAIT ISLANDER

□BOTH □NEITHER

Interpreter Required: NO YES (specify)

Family Details – please specify where relevant

Primary carer:

Date of birth:

Address:

Telephone:

Email:

Other parent/carer:

Address:

Telephone:

Email:

Please indicate which of the following appliesto the young person to assist with priority:

YES / NO
Is the young person currently receiving support from another service/organisation?
Is the young person socially isolated?
Is the young person experiencing financial difficulty?
Does the young person have little/no community participation?
Does the young person have limited access to activities and support?
Does the young person live independently?

The following information will be used to guide the request for support.

Please list the other services you are linked with:

• ______
• ______
• ______
• ______

How would you use your individual package?

□Community Based activities

□Recreational Support

□Group programs/events/workshops

□Family Social Events

□Educational/Personal Development

Goals (please expand on above)

1. ______

1. ______

1. ______

Please return the completed form to the Support Networks Coordinator

Post:

Attention: Julie McDonald

Northcott

Po Box 119

Mayfield NSW 2304

Email:

Your referral will be acknowledged within 7 days.

Should you wish to discuss your referral or if you have any other enquiries, please call the Northcott office and ask to speak with Julie McDonald on 4935 0400.

Northcott Form – Support Networks Referral Form
Owner: Support Networks and Community Development
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File path location:C:\Users\julie.mcdonald\Desktop\Individual Package Forms\Support Networks Individual Packages Referral Form.doc
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