the parent caring for the child and the child both need to be an Australian citizen or have permanent residency status for Australia

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1 The Autism Advisr Prgram is part f the Helping Children with Autism (HCWA) package. The Prgram is funded by the Department f Scial Services is based in QLD at Autism Queensland. Families can access early interventin funds up t $12,000 t use with apprved panel prviders fr services including speech therapy, ccupatinal therapy, psychlgy and/r autism specific prgrams. Families can als access sme free wrkshps and playgrups. Eligibility fr the Helping Children with Autism Early Interventin Funding the child has a cnclusive diagnsis prir t their 6 th birthday f ne f the fllwing: Autism Spectrum Disrder Autistic disrder Asperger s disrder Pervasive Develpment Disrder - Nt Otherwise Specified (PDD-NOS) Childhd Disintegrative Disrder the child has a written, signed and dated Australian diagnsis n letterhead made by ne f these ptins: a paediatrician a psychiatrist a multidisciplinary team (a multidisciplinary team must include bth a psychlgist and a speech language pathlgist wh cnduct a cmbined assessment and diagnsis and prvide a cmbined reprt n letterhead that is dated and signed by bth prfessinals) the parent caring fr the child and the child bth need t be an Australian citizen r have permanent residency status fr Australia a child living in a Natinal Disability Insurance Scheme (NDIS) site cannt apply fr the HCWA funding. Families shuld cntact the Natinal Disability Insurance Agency r Applicatin Steps Step 1: Check yur child is eligible - ensure that yur child meets the eligibility requirements listed abve n this sheet Step 2: Register with the Autism Advisr Prgram by cmpleting an applicatin frm, the cnsent frm and prviding the relevant dcumentatin Ensure that the frms are returned t the Autism Advisr Prgram with the fllwing dcuments:

2 a cpy f the letter/reprt with the diagnsis a cpy f yur child s birth certificate prf f yur child s Centrelink Reference Number (this is yur child s CRN nt yur wn) parenting plans, curt rders r authrity t care rders, if relevant. Where pssible all parents/carers/guardians need t be infrmed that an applicatin fr HCWA has been submitted fr the child prf f citizenship r permanent residency f Australia, if the parent caring fr the child was nt brn in Australia Please nte New Zealand citizens are nt autmatically eligible, prf f residency is required. If yu are receiving the Carer Allwance yu will meet the residency requirement. prf f family s current residential address (e.g. rent r rates ntice) Step 3: Attend an appintment with an Autism Advisr The Autism Advisr Prgram will assist in determining yur child s eligibility fr the Prgram. Once eligible an appintment time will be made with an Autism Advisr wh will advise yu abut the ptins fr early interventin services available thrugh the HCWA package and abut ther services in yur lcal cmmunity. Step 4: Receipt f Letter f intrductin The Autism Advisr Prgram will prvide yu with a letter f intrductin t give t the DSS apprved service prvider f yur chice. Services will be paid directly by DSS fr any services yur child receives. Please nte that the letter f intrductin is nrmally issued t the parent/carer wh first registers the child fr the funding and this letter will be in the name f the persn wh signs the AAP cnsent frm. Hwever, in shared parenting arrangements the ther parent/carer may als be able t btain a secnd letter f intrductin nce they have prvided the relevant dcumentatin t AAP. Bth parents/carers hlding the letters f intrductin are respnsible t ensure they jintly manage the early interventin funding and d nt verspend. Receipt f Outer Reginal & Remte Payment (ORR) Families wh live in an uter reginal area r beynd, accrding t the Australia Bureau f Statistics Accessibility/Remteness Index f Australia classificatin, will receive a ne ff payment f $2,000 fr each child diagnsed with an ASD in additin t the funding package f up t $12,000 per child. Interpreter Service - If required cntact the Autism Advisr Prgram t bk an interpreter. Fr further infrmatin Autism Advisr Prgram (QLD) PO Bx 354, Sunnybank QLD 4109 Phne: // // Fax: Department f Scial Services Web: // T:

3 Details f Child Applicatin Frm Sunnybank Hills 437 Hellawell Rad Sunnybank Hills Qld 4109 PO Bx 354 Sunnybank Qld 4109 Phne Fax Child s First Name: Date f Birth: Gender: Child s Last Name: Child s CRN: (prvide prf) Cuntry f Birth: Parents/Carer/Guardian Infrmatin: (Full Name) (Please cmplete fr bth Parents/Carers if relevant) First Name: (Mr./Mrs./Ms) Last Name: Relatinship t child Hme address: Suburb: Pst Cde: First Name: (Mr./Mrs./Ms) Last Name: Relatinship t child Hme address: Suburb: Pst Cde: Hme number: Wrk Mbile: Hme number: Wrk Mbile: Child lives with: bth natural parents Yes/N mther Yes/N father Yes/N Other Are there any custdy r care arrangements fr this child? Yes/N If yes please utline and attach relevant dcumentatin Diagnsis: Autism Spectrum Disrder Autistic Disrder Pervasive Develpmental Disrder - Nt Otherwise Specified (PDD-NOS) Asperger s Syndrme/Disrder Childhd Disintegrative Disrder Residency status (the parent caring fr the child needs t be brn in Australia r have Australian citizenship r permanent Australian residency status if yu are receiving the carer allwance yu will meet the residency requirement): Australian citizen Permanent Australian residency status Have yu applied fr the Natinal Disability Scheme fr this child? Yes/N Have yu applied fr Carers Allwance? Yes/N Funded by Department f Scial Services based at Autism Qld AAP_Octber 2015

4 Applicatin Frm Sunnybank Hills 437 Hellawell Rad Sunnybank Hills Qld 4109 PO Bx 354 Sunnybank Qld 4109 Phne Fax D yu have anther child/ren with a diagnsis f an autistic spectrum disrder? Yes/N If Yes: Are they receiving the HCWA early interventin funding? Yes/N If Yes: Fr mailing purpses PO BOX Please prvide child/ren s full name/s Instructins This applicatin frm is intended fr families wh live in QLD nly. Family Grss weekly incme: High ($2, r mre) Medium ($ $1,999.00) Lw (less than $600.00) Nt stated. Des yur child have an Indigenus backgrund? Australian Abriginal Yes/N Trres Strait Islander Yes/N D yu speak a language ther than English in the family? Yes/N. If yes, which language(s)? Will yu require an interpreter? Yes/N Hw did yu hear abut the Autism Advisr Prgram? Des yur child have ther significant medical cnditins? Physical disability Attentin Deficit Disrder (ADD)/ Attentin Deficit Hyperactivity Disrder (ADHD) Epilepsy Other Please return this Applicatin Frm and relevant dcuments t: Autism Advisr Prgram (QLD) PO Bx 354 Sunnybank Qld Fax: Dcuments t be attached t Applicatin Frm Tick each bx as the relevant dcument is cpied and attached. Cnsent Frm (cmpleted and signed) Cpy f letter f Diagnsis Cpy f yur child s birth certificate A current rates r rent ntice with yur address Prf f yur Child s Centrelink Reference Number (CRN) the number is n Centrelink Crrespndence/child s health care card Parenting plans fr shared care f yur child, curt rders, authrity t care rders Prf f Australian citizenship r permanent residency f Australia, if the parent caring fr the child was brn verseas. Please nte New Zealand citizens are nt autmatically eligible. Funded by Department f Scial Services based at Autism Qld AAP_Octber 2015

5 Client Cnsent fr Cllectin f Persnal Infrmatin Dear Parent, Carer r Guardian, yu are required t read this dcument t ensure yu understand yur rights and respnsibilities regarding the cllectin f persnal infrmatin fr the purpses f accessing early interventin services under the Helping Children with Autism package/better Start fr Children with Disability initiative befre signing the Client Cnsent n the next page. Helping Children with Autism (HCWA) package and Better Start fr Children with Disability (Better Start) initiative These tw prgrammes aim t assist eligible children with autism r develpmental disabilities t access funding fr early interventin services. As part f these prgrammes the Department f Scial Services (DSS) will prvide funds t service prviders t assist eligible children and their families r carers. Payments fr the services prvided t yu and/r yur child will be made t the service prvider n yur behalf when they submit a claim fr payment (pending the balance f available funding fr yur child). Therefre, infrmatin abut yu and yur child is cllected frm yu by the service prviders fr the purpses f assisting and prviding yu with services under the HCWA/Better Start prgramme. If yu d nt prvide the requested infrmatin, yur child s eligibility t receive funding under the Helping Children with Autism package/better Start fr Children with Disability initiative cannt be determined. Sme f the infrmatin cllected will assist DSS t plan and deliver services fr peple with disabilities. HCWA and Better Start transitining t the Natinal Disability Insurance Scheme (NDIS) Bth the HCWA and Better Start prgrammes are transitining t the NDIS as the NDIS is rlled ut in accrdance with phasing arrangements determined by the Natinal Disability Insurance Agency (NDIA). Sme infrmatin cllected by DSS may be passed n t NDIA t assist NDIA t plan and deliver services fr peple with disabilities. What infrmatin is cllected? The infrmatin listed belw is cllected frm yu by yur service prvider. By signing this frm yu are giving permissin fr yur service prvider t give this infrmatin t DSS. - Yur child s name; - Yur child s date f birth, sex, address, and if yu are an Australian citizen r permanent resident; - Yur child s Centrelink Custmer Reference Number (CRN); and - Yur cntact infrmatin, address, phne number and address. Yu can ask yur service prvider t give yu a written cpy f the infrmatin that they have shared with DSS r fr mre infrmatin, yu can ask them fr a cpy f their APP Privacy Plicy. Prtectin f infrmatin Yur service prvider is bliged t bserve strict privacy rules called the Australian Privacy Principles (APPs) which are cntained in the Privacy Act 1988 (Cth). This means that they must: - Tell yu why they need t cllect yur infrmatin (i.e. t assess yur eligibility fr funding); - Tell yu what they d with yur infrmatin and wh they will give it t (e.g. DSS and any ther parties DSS chses); - Stre the infrmatin securely; - Only use the infrmatin fr the purpses they btained it; and - Only pass yur infrmatin n when the law allws, when yu have cnsented and when yu have been advised f the ther parties t whm yur infrmatin may be given. The infrmatin that is frwarded t DSS is stred in a secure manner and nly a limited number f DSS staff have access t yur persnal infrmatin. Yur infrmatin may als be prvided fr the fllwing purpses t the fllwing grups: 1. Fr the administratin f the prgrammes, specific infrmatin may be prvided t a. cntracted service prviders; and/r b. ther Australian Gvernment departments/rganisatins, particularly the NDIA (due t transitining arrangements). Page 1 f 3

6 2. Fr the purpses f research and evaluating the prgrammes, de-identified infrmatin may be prvided t a. cntracted service prviders; and/r b. ther Australian Gvernment departments/rganisatins. Yur CRN is prtected infrmatin as defined by the Scial Security Act Yur CRN is prtected by the Scial Security (Administratin) Act 1999 and will nly be prvided t DSS with yur cnsent. DSS smetimes prvides infrmatin abut peple wh are accessing Australian Gvernment funded services t ther Australian Gvernment departments and researchers. When this happens, nly limited infrmatin is made available and DSS remves all details that culd identify yu, e.g. yur name. This is s n ne will be able t identify the infrmatin as belnging t yu. The ther gvernment departments and researchers wh are given access t yur persnal infrmatin must als bserve the Australian Privacy Principles when handling the infrmatin. The Federal Privacy Cmmissiner can investigate allegatins f imprper cllectin, use and disclsure f persnal infrmatin by gvernment departments. DSS has a Privacy Plicy which utlines infrmatin n the cllectin f persnal infrmatin and the Australian Privacy Principles. This plicy can be fund at: General enquiries and requests t access r crrect persnal infrmatin If yu wish t: query hw yur persnal infrmatin is cllected, held, used r disclsed; ask questins abut this Privacy Plicy; btain access t r seek crrectin f yur persnal infrmatin; please cntact the DSS Cmpliments and Enquiries area using the fllwing cntact details: pst: DSS Feedback, PO Bx 7576, Canberra Business Centre ACT Cntact details fr privacy cmplaints If yu wish t make a cmplaint abut a breach f yur privacy, please cntact the DSS Feedback and Crdinatin team using the fllwing cntact details: telephne: fax: (02) pst: DSS Feedback, PO Bx 7576, Canberra Business Centre, Page 2 f 3

7 Client Cnsent Frm Client Cnsent fr Cllectin f Persnal Infrmatin Name f Child The persnal infrmatin as listed abve is cllected frm yu by the service prvider fr the purpses f determining yur child s eligibility t receive funding under the Helping Children with Autism package/better Start fr Children with Disability initiative and future research and evaluatin f these prgrammes. The service prvider is required t pass this infrmatin t DSS. DSS may then prvide yur infrmatin t a cntracted service prvider and/r t anther Australian Gvernment department/rganisatin fr administratin, research and evaluatin purpses. I (name f parent, carer, r guardian) Of (address) have read this dcument and hereby give cnsent fr the service prvider t disclse, as required, my infrmatin t DSS. I understand that DSS may then prvide my infrmatin t a cntracted service prvider and/r t anther Australian Gvernment department/rganisatin fr administratin, research and evaluatin purpses. I acknwledge that the disclsure f sme r all f my infrmatin will ccur fr the purpse f assisting the Australian Gvernment t manage its respnsibilities. Parent, Carer/Guardian signature / / I give cnsent fr the Autism Advisr Prgram based at Autism Qld t cntact relevant prfessinals t clarify aspects f my child s diagnsis t allw prcessing f the applicatin fr the HCWA package. Parent, Carer/Guardian signature / / Please nte the cnsent frm shuld be signed by ne parent/carer and the letter f intrductin will be issued in the name f the parent/care wh first registers the child fr the HCWA funding. Hwever, in shared care arrangements a secnd letter f intrductin may be issued t the ther parent/carer nce they have prvided the relevant dcumentatin t AAP. Page 3 f 3

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