Autism Advisor Program NSW Application Form
Other significant medical conditions
Do you have any other children who have received or are receiving the funding?
Have you previously applied for the National Disability Insurance Scheme for this child?
Have you previously applied for the Better Start Program?
Parent/Carer Details Main Contact:
* Title Dr Miss Mr Mrs Ms Contact 2 (optional) Contact 3 (optional) *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. Language and Culture
Is your child of Aboriginal or Torres Islander descent?
Do you speak another language at home?
Do you need an interpreter service?
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.
Gross Family Weekly Income
How did you hear about the Autism Advisor Program? These documents MUST be attached in order for your application to be processed These documents are to be attached if they are available and/or relevant to your child
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
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 completing the client consent below.
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.
What information is collected?
The information listed below is collected from you by your service provider. By signing this form you are 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 email address.
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.
The information that is forwarded to DSS is stored in a secure manner and only a limited number of DSS staff have access to your personal information. Your information may also be provided for the following purposes to the following groups:
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). 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 1991. 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.
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.
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;
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 2610. *please note these contact details are for questions relating to the collection of personal information only, do not send your application to this address.
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: 1800 634 035
fax: (02) 6133 8442
post: DSS Feedback, PO Box 7576, Canberra Business Centre, 2610.
*please note these contact details are for feedback and complaints only, do not send your application to this address.
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.
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.
Office use only - Compliance with Australian Privacy Principles
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
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.
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.
“ When living with a neurological condition (or with a loved one who has one), it can be very easy to focus on the challenges and limitations. But in my life, I have found that focusing on abilities, finding new ways to adapt, have been crucial to my successes in life. Seeking those solutions can even be seen as a form of creativity. ”
— Lynn Soraya Browse