Autism Advisor Program NSW

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1 What is the Autism Advisor Program? Information Sheet The NSW Autism Advisor Program offers the following support to families: information about autism spectrum disorders information about family support and therapy options access to up to $12,000 funding to spend on early intervention services How do I know if my child is eligible? The program is available for families and carers of children who: have registered with the Autism Advisor Program prior to their 6 th birthday have a conclusive diagnosis of a Pervasive Developmental Disorder (see below for more information) are citizens, permanent residents of Australia or would meet these requirements (this applies to both the carer and the child being cared for). If you or your child were born outside of Australia you will be required to provide proof of your residency status. Please note New Zealand citizens are not automatically eligible, proof of permanent residency is required. National Disability Insurance Scheme Please note families living in the Newcastle, Lake Macquarie and Maitland Local Government Areas should register with National Disability Insurance Agency or Families cannot apply for both the Helping Children with Autism Funding and the National Disability Insurance Scheme. What kind of diagnosis is needed? B A conclusive diagnosis is needed of one of the following conditions: Autism Autism Spectrum Disorder Autistic Disorder Asperger s Syndrome/Disorder Childhood Disintegrative Disorder Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) The child will need a written and signed Australian diagnosis on letterhead made via one of these options: Paediatrician Psychiatrist A multidisciplinary team (a multidisciplinary team must include both a psychologist and speech therapist. The therapists need to conduct a combined assessment and diagnosis and sign the report) Please note that having characteristics/features/symptoms of autism is not a conclusive diagnosis. For more information contact an Autism Advisor on For a language interpreter call The NSW Autism Advisor Program is committed to supporting the needs of people from culturally and linguistically diverse backgrounds. Autism Advisor Program. P a g e 1

2 Child first name: Date of birth: Diagnosis: Country of Birth: Application Form If you need help to complete this form, call us on Please print clearly Autistic Disorder (Autism) Autism Spectrum Disorder Child surname: Asperger s Disorder (Asperger syndrome) Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Residency status: (Please see information sheet and provide proof where necessary) Child s Centrelink Reference Number (CRN): Other significant medical conditions: Physical disability Epilepsy ADHD ADD Other Australian citizen Permanent Resident Other (please contact us to check eligibility) Do you have any other children who have received or are receiving the funding? Yes No Have you previously applied for the National Disability Insurance Scheme for this child? Yes No Have you previously applied for the Better Start Program? Yes No Parent/Carer Details: Main contact name: (Mr/Mrs/Ms): Mobile: Home address: (If you live in an NDIS area please contact NDIA see page 1 for details) Suburb: *: Home number: Work number: Autism Advisor Program. P a g e 2 Fax: Postcode: *If you supply an address, the Autism Advisor Program and DSS will use it to send through important information to you. Please print clearly Relationship to Parent child: Grandparent Contact 2 name (optional):* (Mr/Mrs/Ms): Relationship to Parent/Carer child: Grandparent Contact 3 name (optional):* (Mr/Mrs/Ms): Relationship to child: Parent/Carer Grandparent Other relative: Friend Other relative: Friend Other relative: Friend Contact number: Service Provider Case Worker Contact number: Service Provider Case Worker Other: Service Provider Guardian/Advocate Other: Guardian/Advocate Other: *You may include contacts for any significant person in your child s life who has legal rights and / or responsibilities or someone providing your family with significant support. These are people we may be in contact with regarding your child. If you are unsure please speak with an Autism Advisor or add comments here. An example may be where there is a formal or informal shared care arrangement. If there are formal court orders which prevent access to the child from a specific person please send in a copy.

3 Language and Culture: Is your child of Aboriginal or Torres Islander descent? Y / N What is the main language you speak at home? Australian Aboriginal Torres Strait Islands Neither Do you speak another language at home? Yes No If yes, which language(s)? Do you need an interpreter service? Yes No Gross Family Weekly Income The Gross Family Weekly Income is the total of the gross individual incomes of each family member 15 years and older living in a household. Family income only applies to families in occupied private dwellings. Family income is not applicable to non-family households such as group households or lone person households; or to people in nonprivate dwellings. Please note that this is for research only and your answer will not affect your application to the Autism Advisor program. $2,000 or more (per week) $600 - $1,999 (per week) Under $600 (per week) Nil income (Centrelink benefits only) How did you hear about the Autism Advisor Program? Autism Spectrum Australia (Aspect) Medical practitioner (psychiatrist/paediatrician/ GP) Other autism / disability organisation State / territory government service Playgroups Australia or Playconnect playgroups Childcare / preschool / education Allied health professional (speech therapist / psychologist / occupational therapist) Friend / relative / other parent DSS and / or Helping Children With Autism workshop, website, inquiry line Other (please specify) These documents MUST be attached in order for your application to be processed Consent Forms (there are two forms to be completed, both are attached) Copy of Diagnosis (Please check the diagnosis requirements provided on the information sheet) Proof of your child s birth date (please provide a birth certificate, where this is not possible you can also send in an immunisation record, Blue Book or similar) Proof of your home address (utilities or rates invoice) Proof of your child s Centrelink Reference Number (CRN) (child s health care card or Centrelink statement) N.B please send documentation with your child s CRN on it not your own CRN Where necessary, proof of your residency status and/or your child s (please refer to information sheet) These documents are to be attached if they are available and/or relevant to your child Shared care/court orders If there are any parenting plans in place for shared care of your child or court orders that may impact on your child s residence or prevent access to the child from a specific person, please provide copies of relevant documents. Court orders must be attached if the child is in the care of anyone other than the parents as stated on the birth certificate e.g. foster carers, grandparent carers Copy of Treatment Plan If you have any questions, please contact us on Please send this Application Form and documents (preferably by with PDF attachments or fax, if not via post is acceptable. Please note that there is an limit of 10MB. If a file is sent over 10MB you will receive a non-delivery report from our servers. If your file is bigger than this, please separate into several s) to: Autism Advisor Program (NSW) Autism Spectrum Australia (Aspect) PO Box 361 Forestville NSW 2087 Phone: Fax: Autism Advisor Program. P a g e 3

4 Consent Information Dear Parent, Carer or Guardian, you are required to read this document to ensure you understand your rights and responsibilities regarding the collection of personal information for the purposes of accessing early intervention services under the Helping Children with Autism package/better Start for Children with Disability initiative before signing the Client Consent on the next page. Helping Children with Autism (HCWA) package and Better Start for Children with Disability (Better Start) initiative These two programmes aim to assist eligible children with autism or developmental disabilities to access funding for early intervention services. As part of these programmes the Department of Social Services (DSS) will provide funds to service providers to assist eligible children and their families or carers. Payments for the services provided to you and/or your child will be made to the service provider on your behalf when they submit a claim for payment (pending the balance of available funding for your child). Therefore, information about you and your child is collected from you by the service providers for the purposes of assisting and providing you with services under the HCWA/Better Start programme. If you do not provide the requested information, your child s eligibility to receive funding under the Helping Children with Autism package/better Start for Children with Disability initiative cannot be determined. Some of the information collected will assist DSS to plan and deliver services for people with disabilities. HCWA and Better Start transitioning to the National Disability Insurance Scheme (NDIS) Both the HCWA and Better Start programmes are transitioning to the NDIS as the NDIS is rolled out in accordance with phasing arrangements determined by the National Disability Insurance Agency (NDIA). Some information collected by DSS may be passed on to NDIA to assist NDIA to plan and deliver services for people with disabilities. giving permission for your service provider to give this information to DSS. - Your child s name; - Your child s date of birth, sex, address, and if you and your child are Australian citizens or permanent residents; - Your child s Centrelink Customer Reference Number (CRN); and - Your contact information, address, phone number and address. You can ask your service provider to give you a written copy of the information that they have shared with DSS or for more information, you can ask them for a copy of their APP Privacy Policy. Protection of information Your service provider is obliged to observe strict privacy rules called the Australian Privacy Principles (APPs) which are contained in the Privacy Act 1988 (Cth). This means that they must: - Tell you why they need to collect your information (i.e. to assess your eligibility for funding); - Tell you what they do with your information and who they will give it to (e.g. DSS and any other parties DSS chooses); - Store the information securely; - Only use the information for the purposes Aspect obtained it for; and - Only pass your information on when the law allows, when you have consented and when you have been advised of the other parties to whom your information may be given. What information is collected? The information that is forwarded to DSS is The information listed below is collected from you by stored in a secure manner and only a limited your service provider. By signing this form you are number of DSS staff have access to your personal information. Your information may also Autism Advisor Program. P a g e 4

5 be provided for the following purposes to the following groups: 1. For the administration of the programmes, specific information may be provided to a. contracted service providers; and/or b. other Australian Government departments/organisations, particularly the NDIA (due to transitioning arrangements). 2. For the purposes of research and evaluating the programmes, de-identified information may be provided to a. contracted service providers; and/or b. other Australian Government departments/organisations. Your CRN is protected information as defined by the Social Security Act Your CRN is protected by the Social Security (Administration) Act 1999 and will only be provided to DSS with your consent. DSS sometimes provides information about people who are accessing Australian Government funded services to other Australian Government departments and researchers. When this happens, only limited information is made available and DSS removes all details that could identify you, e.g. your name. This is so no one will be able to identify the information as belonging to you. General enquiries and requests to access or correct personal information If you wish to: query how your personal information is collected, held, used or disclosed; ask questions about this Privacy Policy; obtain access to or seek correction of your personal information; please contact the DSS Compliments and Enquiries area using the following contact details: post: DSS Feedback, PO Box 7576, Canberra Business Centre ACT Contact details for privacy complaints If you wish to make a complaint about a breach of your privacy, please contact the DSS Feedback and Coordination team using the following contact details: telephone: fax: (02) post: DSS Feedback, PO Box 7576, Canberra Business Centre, The other government departments and researchers who are given access to your personal information must also observe the Australian Privacy Principles when handling the information. The Federal Privacy Commissioner can investigate allegations of improper collection, use and disclosure of personal information by government departments. DSS has a Privacy Policy which outlines information on the collection of personal information and the Australian Privacy Principles. This policy can be found at: Application Form and Consent Form will only be used by Autism Spectrum Australia (Aspect) for the purposes of creating a Client Record under the Autism Advisor Program. P a g e 5

6 Client Consent Form Client Consent for Collection of Personal Information The personal information as listed above is collected from you by the service provider for the purposes of determining your child s eligibility to receive funding under the Helping Children with Autism package/better Start for Children with Disability initiative and future research and evaluation of these programmes. The service provider is required to pass this information to DSS. DSS may then provide your information to a contracted service provider and/or to another Australian Government department/organisation for administration, research and evaluation purposes. I (name of parent, carer, or guardian) Of (address) have read this document and hereby give consent for the service provider to disclose, as required, my information to DSS. I understand that DSS may then provide my information to a contracted service provider and/or to another Australian Government department/organisation for administration, research and evaluation purposes. I acknowledge that the disclosure of some or all of my information will occur for the purpose of assisting the Australian Government to manage its responsibilities. Parent, Carer or Guardian signature / / Office use only - Compliance with Australian Privacy Principles I (name of Authorised Officer) Of (outlet name) (Agreement Schedule ID) ASPECT 1-M3V5MD have read and explained to the child s parent, carer or guardian. I believe they understand that: the personal information they are asked to provide is collected for the purpose of determining access to and delivery of funding under the Helping Children with Autism package/better Start for Children with Disability initiative; and this service outlet is required, to pass some or all of this information to DSS. DSS may then provide this information to a contracted service provider and/or to another Australian Government department/organisation for administration, research and evaluation purposes. Outlet s signature (Authorised officer) / / Application Form and Consent Form will only be used by Autism Spectrum Australia (Aspect) for the purposes of creating a Client Record under the Autism Advisor Program. P a g e 6

7 Aspect Parent/Guardian Consent Information Protection of information The collection and management of information by the NSW Autism Advisor Program is governed by the Privacy Act 1988 and the information Privacy Principles. The information that is forwarded to DSS and Aspect is stored in a secure manner and only a limited number of authorised staff have access to your personal information. Complaints about the management of personal information are addressed in accordance with the Information Privacy Principles in the Privacy Act What information is collected? All the information that is requested on the NSW Autism Advisor Program application form is shared with DSS and Aspect including your child s name, date of birth, address, sex, Centrelink Reference Number and parent/guardian contact details. Parent/Guardian Consent for Autism Spectrum Australia (Aspect) to Collect and Disclose Personal Information Autism Spectrum Australia (Aspect) requires your consent to collect personal information to provide data to the Autism Advisor Program. Aspect uses the personal information you provide to respond to your request or application for service, for managing and administering the services we provide to you or the person mentioned above and the administration of Aspect s business operations. Aspect may also use the personal information you provide for the purposes of evaluation, research and improvement of Aspect s services and management. I consent to Autism Spectrum Australia (Aspect) contacting me for the purposes outlined above. Please tick one box. Yes: No: Parent/Guardian signature Parent/Guardian name Parent/Guardian Application Form and Consent Form will only be used by Autism Spectrum Australia (Aspect) for the purposes of creating a Client Record under the Autism Advisor Program. P a g e 7

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