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. Please note families living in the Newcastle Local Government Area should register with Disability Care Australia 1800 800 110 or www.disabilitycareaustralia.gov.au What kind of diagnosis is needed? 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 Australian diagnosis on letterhead made via one of these options: Paediatrician Psychiatrist A multidisciplinary team (a multidisciplinary team must include a psychologist, speech therapist but may also include an occupational therapist with autism expertise. The therapists need to conduct a combined assessment and sign the report) State/territory Autism Association (Autism Spectrum Australia) Please note that having characteristics/features/symptoms of autism is not a conclusive diagnosis. For more information contact an Autism Advisor on 1300 978 611 For a language interpreter call 13 14 50 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
Child Details: Child first name: Application Form If you need help to complete this form, call us on 1300 978 611 Please print clearly Child surname: Date of birth: Diagnosis: Autistic Disorder (Autism) Autism Spectrum Disorder Asperger s Disorder (Asperger syndrome) Pervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS) Childhood Disintegrative Disorder Other significant medical conditions: Physical disability Epilepsy ADHD ADD Other Australian citizen Country of Birth: Residency status: Permanent Resident (Please see information sheet and provide proof where necessary) Other (please contact us to check eligibility) Do you have any other children who have or are receiving the funding? Yes No Parent/Carer Details: Primary contact name: (Mr/Mrs/Ms): Mobile: Home address: (If you live in Newcastle LGA please contact Disability Care Australia) Suburb: Email*: Home number: Work number: Fax: Postcode: *If you supply an email address, the Autism Advisor Program and FaHCSIA will use it to send through important information to you Relationship to child: Additional contact name:* Relationship to child: Parent Grandparent Other relative: Parent / Carer Grandparent Other relative: Friend Contact number: Friend Service Provider Other: Service Provider Case Worker Guardian / Advocate Other: *An additional contact may be another significant person in the child s life who has legal rights and / or responsibilities. 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. Autism Advisor Program. P a g e 2
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 non-private 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 FaHCSIA 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, 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 1300 978 611. Please send this Application Form and documents (preferably by fax or email, if not via post is acceptable) to: Autism Advisor Program (NSW) Autism Spectrum Australia (Aspect) PO Box 937 Alstonville NSW 2477 Phone: 1300 978 611 Fax: 02 9975 1633 Email: autismadvisor@autismspectrum.org.au Autism Advisor Program. P a g e 3
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 before signing the Client Consent on the next page. Why is information collected? Information about you and your child is collected to enable Autism Spectrum Australia (Aspect) to give you and your child the service you need. It is also collected by Aspect to enable Aspect to comply with its obligations under its funding agreement with the Australian Government Department of Social Services (DSS). DSS gives service providers money to help people with disability. The information you provide assists DSS to ensure you can get the right type of help, and enables DSS to plan for the future. It also enables DSS to meet its own accountability requirements under the Financial Management and Accountability Act 1997 (Cth). What information is collected? The information listed below is collected from you by Aspect. By signing this form you are giving consent for Aspect 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 email address. You can ask Aspect to give you a written copy of the information that they have shared with DSS. Protection of information Aspect is obliged, under the terms of Aspect s funding agreement, to observe strict privacy rules called Information Privacy Principles ( IPPs ) which are contained in the Privacy Act 1988 ( Privacy Act ). This means that Aspect 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. DSS is also under an obligation to comply with the Information Privacy Principles, under the Privacy Act. The information that is forwarded to DSS is stored by DSS in a secure manner and only a limited number of DSS staff have access to your personal information. DSS sometimes provides information about people who are accessing Australian Government funded services to other government agencies, authorities, and researchers (including research organisations). 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. The other government agencies, authorities, researchers who are given access to your personal information must also observe the Information Privacy Principles when handling the information. The Federal Privacy Commissioner can investigate allegations of improper collection, use and disclosure of personal information by funded service providers and government agencies and authorities. Helping Children with Autism Package Under the increased access to early intervention component of the package, payments are made (in arrears) on your behalf for services you received under the package. The payment will be made to your service on your behalf when your service provider submits a claim for payment (pending the balance of available funding for your child). Autism Advisor Program. P a g e 4
Client Consent Form Please complete all parts of this form. Client Consent for Disclosure and Use of Personal Information The personal information about you and your child that you are asked to provide is collected to determine your child s eligibility to receive funding under the Helping Children with Autism package. Aspect is obliged to disclose this information to DSS and/or it may be disclosed to another agency, authority, researcher or organisation as directed by the Australian Government, as specified in its funding agreement with DSS. I (name of parent, carer, or guardian) Of (address) give consent for Aspect to disclose, as required, my personal information (and my child s personal information) to DSS or any other agency, authority, researcher or organisation directed by the Australian Government. I acknowledge that the disclosure of some or all of my information to the Australian Government will occur for the purpose of assisting the Australian Government to comply with its obligations under the Financial Management and Accountability Act 1997, and to assist it with research, evaluation, and monitoring of DSS programs (and DSS funding recipients). Parent, Carer or Guardian signature / / Please also complete this section I (name of Individual providing the consent) Acknowledge that I have read and understand the Client Consent Information and the Client Consent Form, as it applies to the personal information of me and my child. Parent, Carer or Guardian Signature / / Autism Advisor Program. P a g e 5
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 1988. 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 Autism Advisor Program. P a g e 6