Helping Children with Autism (HCWA) Application Victorian ... Children with Autism (HCWA) Application Victorian Application Form ... proof of Australian citizenship or permanent residency. ... (HCWA) Application

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Helping Children with Autism (HCWA) Application Victorian Application Form Webform 20161129 1 1. Information about your child Childs Surname Childs First Name Childs Date of Birth Year of School Entry Boy Girl Childs Centrelink Reference Number (CRN) 2. Information about your family Email address* Do you wish to join our mailing list to receive updates from Amaze about ASD events, information and special offers? Yes No *Please provide a valid email address to receive family activity statements outlining your childs remaining funding allocation. If you do not have an email address, please be aware your balance statements will be posted to you and may be delayed. Residential Address Address: Suburb/Town: State: Postcode: Primary Contact Name Title: Mr, Mrs, Ms, Miss Relationship to child Mother Father Other Contact number (H) (Mob) (W) Other Contact Name (If applicable) Title: Mr, Mrs, Ms, Miss Relationship to child Mother Father Other Contact number (H) (Mob) (W) Other Children in the family Siblings Name Date of Birth Does this child have an ASD? Sibling 1 Yes No Sibling 2 Yes No Sibling 3 Yes No 3. Type of consultation preferred Telephone consult Face to face consult (please note that we do not do home visits) Skype consult Helping Children with Autism (HCWA) Application Victorian Application Form Webform 20161129 2 4. Information about ethnicity and residency Is your child of Aboriginal or Torres Strait Islander descent? Aboriginal Torres Strait Islander Neither What is your childs country of birth? Note: If your child was born outside Australia, or if both parents were born overseas, you will need to attach proof of Australian citizenship or permanent residency. What is your childs residency status? Australian citizen Permanent resident Other (Please specify) Main language spoken at home If English is not your first language, do you require an interpreter? Yes No 5. Service information Please outline the services your child is currently attending (if any). Service/Therapy Program Provider/Therapist Is therapist on the HCWA approved panel? Yes No Unsure Yes No Unsure Yes No Unsure 6. Other conditions Does your child have any conditions in addition to an Autism Spectrum Disorder that will be considered in relation to their early intervention program? Epilepsy Intellectual Disability Attention Deficit (Hyperactivity) Disorder (ADD or ADHD) Global Developmental Delay Other (Please give details) 7. Information for statistical purposes How did you first hear about the Autism Advisor/HCWA Program? Amaze or other state Autism Association Playgroups Australia and/or Playgroups (PlayConnect) (please circle) State/territory funded service FaHCSIA/DSS/HCWA website Allied health professional and/or multi-disciplinary team (psychologist, speech pathologist, occupational therapist) Early Days Workshop Aboriginal Liaison Officer Other Other autism/disability organisation Medical practitioner: psychiatrist, paediatrician, GP Childcare/preschool/education Friend/relative/other parent Autism Specific Early Learning and Childcare Centre Early Intervention Panel Provider Helping Children with Autism (HCWA) Application Victorian Application Form Webform 20161129 3 What is your gross family weekly income? $ Please note that answering this question will not affect your eligibility to receive the HCWA funding: it is a routine question for FaHCSIAs data collection purposes. Less than $600 per week $600 to $1999 per week $2000 or more per week 8. Assistance with access Did someone else help you fill in this form? Yes No (if no, go to section 9) Do we have permission to talk to this person if necessary? Yes No If yes, please provide this persons contact details Name: Relationship to family: (e.g. case worker, relative, friend) Phone Number: 9. Consent to contact professionals The Autism Advisors may need to contact the professionals who diagnosed your child to clarify aspects of the diagnosis or to ask them to send more information. This will allow the Advisors to process your childs application more quickly. Do you give permission for the Advisors to do this (please tick and sign). Yes No Signed: Date: 10. Consent to process application I, (parent/guardian name) give Amaze permission to enter and access the details for my child (childs name) on the FaHCSIA Online Financial Management System and Amaze internal system. I have read and signed the Privacy Statement on the following pages. The information I have provided is true and correct. Also I confirm that I have custody of the child and there are no ongoing custody disputes regarding their care. (Please call the Advisor Line on 1300 424 499 if you wish to discuss this further.) Signed: Date: I give consent for FaHCSIA or an organisation on behalf of FaHCSIA to contact me directly about my childs funding if required: Yes No Application Checklist I have enclosed copies of: My childs unique Centrelink Reference Number (CRN) (e.g. healthcare card, Centrelink letter, MyGov print out) My childs birth certificate A rates notice or utilities bill with my current address A signed letter of diagnosis from a paediatrician, psychiatrist, or multi-disciplinary team (psychologist and speech therapist) Proof of Australian citizenship or permanent residency (if both parents were born overseas) I have signed the consent boxes above Return completed form and supporting documentation to: Autism Advisor Service, Amaze PO Box 374, Carlton South VIC 3053 Helping Children with Autism (HCWA) Application Victorian Application Form 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 before signing the Client Consent on the next page. Why is information collected? Information about you and your child is collected to enable Amaze to give you and your child the service you need. It is also collected by to enable Amaze to comply with its obligations under its funding agreement with the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). FaHCSIA gives service providers money to help people with disability. The information you provide assists FaHCSIA to ensure you can get the right type of help, and enables FaHCSIA to plan for the future. It also enables FaHCSIA 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 Amaze. By signing this form you are giving consent for Amaze to give this information to FaHCSIA. Your childs name; Your childs date of birth, sex, address, and if you and your child are Australian citizens or permanent residents; Your childs Centrelink Customer Reference Number (CRN); and Your contact information, address, phone number and email address. You can ask Amaze to give you a written copy of the information that they have shared with FaHCSIA. Protection of information Amaze is obliged, under the terms of Amaze, to observe strict privacy rules called, National Privacy Principles (NPP) which are contained in the Privacy Act 1988 (Privacy Act). This means that Amaze 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. FaHCSIA and any other parties FaHCSIA chooses); Store the information securely; Only use the information for the purposes Amaze 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. FaHCSIA is also under an obligation to comply with the Information Privacy Principles, under the Privacy Act. The information that is forwarded to FaHCSIA is stored by FaHCSIA in a secure manner and only a limited number of FaHCSIA staff have access to your personal information. FaHCSIA 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 FaHCSIA 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 (HCWA) Application Victorian Application Form Webform 20161129 5 Client Consent 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 childs eligibility to receive funding under the Helping Children with Autism package. Amaze is obliged to disclose this information to FaHCSIA 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 FaHCSIA. I, (name of parent, carer, or guardian) of (address) give consent for Amaze to disclose, as required, my personal information (and my childs personal information) to FaHCSIA 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 FaHCSIA programs (and FaHCSIAs funding recipients). I 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 / /


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