Helping Children with Autism Application Form - Amaze

1. Information about your childChild’s SurnameHelping Children with Autism (HCWA):Victorian Autism Advisor Service: Privacy NoticeChild’s First NameChild’s Date of Birth Year of School Entry Boy Girl2. Information about your familyEmail address*Do you wish to receive our eSpectrum online newsletter?This provides regular updates about changes to the HCWA package andinformation relating to ASDs. Yes No Already subscribed*Please provide a valid email address to receive family activity statements outlining your child’s remaining funding allocation. If you do not havean email address, please be aware your balance statements will be posted to you and may be delayed.Residential AddressAddress:Suburb/Town: State: Postcode:Primary Contact NameTitle: Mr, Mrs,Ms, MissRelationship to child Mother Father OtherContact number (H) (Mob) (W)Other Contact Name(If applicable)Title: Mr, Mrs,Ms, MissRelationship to child Mother Father OtherContact number (H) (Mob) (W)Other Children in the familySibling’s Name Date of Birth Does this child have an ASD?Sibling 1 Yes NoSibling 2 Yes NoSibling 3 Yes NoSibling 4 Yes No3. 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):Victorian Autism Advisor Service: Application Form4. Information about ethnicity and residencyIs your child of Aboriginal or Torres StraitIslander descent?What is your child’s country of birth? Aboriginal Torres Strait Islander NeitherNote: If your child was born outside Australia, or if both parents were born overseas, you will need to attach proof of Australian citizenship orpermanent residency.What is your child’s residency status? Australian citizen Permanent resident OtherMain language spoken at homeIf English is not your first language,do you require an interpreter?(Please specify) Yes No5. Service informationPlease outline the services your child is currently attending (if any)Service/Therapy Program Provider/Therapist Is therapist on FaHCSIA’s approved panel? Yes No Unsure Yes No Unsure Yes No Unsure6. Other conditionsDoes your child have any conditions in addition to an Autism Spectrum Disorder that will be considered in relation to theirearly intervention program? Epilepsy Attention Deficit (Hyperactivity) Disorder (ADD or ADHD) Other (Please give details) Intellectual Disability Global Developmental Delay7. Information for statistical purposesHow did you first hear about the Autism Advisor/HCWA Program? Autism Victoria or other state Autism Association Playgroups Australia and/or Playgroups (PlayConnect) State/territory government service FaHCSIA/HCWA website, workshops, inquiry line Other autism/disability organisation Medical practitioner (psychiatrist, paediatrician, GP Childcare/preschool/education Friend/relative/other parent Allied health professional and/or multi-disciplinary team (psychologist, speech pathologist, occupational therapist) OtherWhat 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 FaHCSIA’s datacollection purposes. Less than $600 per week $600 to $1999 per week $2000 or more per week

Helping Children with Autism (HCWA):Victorian Autism Advisor Service: Application Form8. Assistance with accessDid someone else help you fill in this form? Yes No (if no, go to section 9)Do we have permission to talk to this personif necessary? Yes NoIf yes, please provide this person’s contactdetailsName:Relationship to family:(e.g. case worker, relative, friend)Phone Number:9. Consent to contact professionalsThe Autism Advisors may need to contact the professionals who diagnosed yourchild to clarify aspects of the diagnosis or to ask them to send more information.This will allow the Advisors to process your child’s application more quickly. Do yougive permission for the Advisors to do this (please tick and sign). YesSigned:Date: No10. Consent to process applicationI, (parent/guardian name) give Autism Victoria trading as Amaze permission to enter and access thedetails for my child(child’s name) on the FaHCSIA Financial Management System. I have read andsigned the Privacy Statement on the following pages. The information I have provided is true and correct. Also I confirm that I havecustody of the child and there are no ongoing custody disputes regarding their care. (Please call the AdvisorLine on 1300 424 499 if you wish todiscuss this further.)Signed:Date:I give consent for FaHCSIA or an organisation on behalf of FaHCSIA to contact me directly about my child’s funding if required: Yes NoApplication ChecklistI have enclosed copies of: My child’s birth certificate A rate’s notice or utilities bill with my current address My child’s Centrelink Reference Number (CRN) – the number on his/her Health Care Card 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 aboveReturn completed form and supporting documentation to:Autism Advisor ServiceAmaze (Autism Victoria)PO Box 374, Carlton South VIC 3053

Helping Children with Autism (HCWA):Victorian Autism Advisor Service: Application FormConsent InformationDear Parent, Carer, or Guardian, you are required to read this document to ensure youunderstand your rights and responsibilities regarding the collection of personal informationfor the purposes of accessing early intervention services under the Helping Children withAutism package before signing the Client Consent on the next page.Why is information collected?Information about you and your child is collected toenable Amaze (Autism Victoria) to give you and yourchild the service you need. It is also collected byAmaze (Autism Victoria) to enable Amaze to complywith its obligations under its funding agreement withthe Australian Government Department of Families,Housing, Community Services and IndigenousAffairs (FaHCSIA). FaHCSIA gives service providersmoney to help people with disability. The informationyou provide assists FaHCSIA to ensure you can getthe right type of help, and enables FaHCSIA to planfor the future. It also enables FaHCSIA to meet itsown accountability requirements under the FinancialManagement and Accountability Act 1997 (Cth).What information is collected?The information listed below is collected from you byAmaze (Autism Victoria). By signing this form youare giving consent for Amaze (Autism Victoria) togive this information to FaHCSIA.- Your child’s name;- Your child’s date of birth, sex, address, and ifyou and your child are Australian citizens orpermanent residents;- Your child’s Centrelink Customer ReferenceNumber (CRN); and- Your contact information, address, phonenumber and email address.You can ask Amaze (Autism Victoria) to give you awritten copy of the information that they have sharedwith FaHCSIA.Protection of informationAmaze (Autism Victoria) is obliged, under the termsof Amaze (Autism Victoria), to observe strict privacyrules calledInformation Privacy Principles (‘IPPs’) which arecontained in the Privacy Act 1988 (‘Privacy Act’). Thismeans that Amaze (Autism Victoria) 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 whothey will give it to (e.g. FaHCSIA and any otherparties FaHCSIA chooses);- Store the information securely;- Only use the information for the purposes Amaze(Autism Victoria) obtained it for; and- Only pass your information on when the law allows,when you have consented and when you have beenadvised of the other parties to whom your informationmay be given.FaHCSIA is also under an obligation to comply withthe Information Privacy Principles, under the PrivacyAct. The information that is forwarded to FaHCSIA isstored by FaHCSIA in a secure manner and only alimited number of FaHCSIA staff have access to yourpersonal information.FaHCSIA sometimes provides information aboutpeople who are accessing Australian Governmentfunded services to other government agencies,authorities, and researchers (including researchorganisations). When this happens, only limitedinformation is made available and FaHCSIA removesall details that could identify you, e.g. your name. Thisis so no one will be able to identify the information asbelonging to you.The other government agencies, authorities,researchers who are given access to your personalinformation must also observe the Information PrivacyPrinciples when handling the information. The FederalPrivacy Commissioner can investigate allegations ofimproper collection, use and disclosure of personalinformation by funded service providers andgovernment agencies and authorities.

Helping Children with Autism (HCWA):Victorian Autism Advisor Service: Privacy NoticeClient Consent FormClient Consent for Disclosure and Use of Personal InformationThe personal information about you and your child that you are asked to provide is collected to determine yourchild’s eligibility to receive funding under the Helping Children with Autism package. Amaze (Autism Victoria) isobliged 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 withFaHCSIA.I (name of parent, carer, or guardian)Of (address)give consent for Amaze (Autism Victoria) to disclose, as required, my personal information (and my child’spersonal information) to FaHCSIA or any other agency, authority, researcher or organisation directed by theAustralian Government. I acknowledge that the disclosure of some or all of my information to the AustralianGovernment will occur for the purpose of assisting the Australian Government to comply with its obligations underthe Financial Management and Accountability Act 1997, and to assist it with research, evaluation, and monitoringof FaHCSIA programs (and FaHCSIA’s funding recipients).I acknowledge that I have read and understand the Client Consent Information and the Client Consent Form, as itapplies to the personal information of me and my child.Parent, Carer or Guardian signature / /