Breakaway Flexible Respite

Breakaway Flexible Respite

Application Form

A target group assessment may be requested to confirm whether a person has a disability as defined by the Disability Act 2006. If the customer is already registered with DHHS, or has undergone a TGA with another disability organisation please submit documentation.Please refer to the Breakaway Guidelines for more information.

Applications must be received by the dates provided on page 7 of this application. All sections must be completed. We are not able to process incomplete applications. If you are a carer or family member and need further assistance to complete this form, please contact us on 9831 5660.

An Authority to Gain and Release Information, hand signed and dated bythe Primary Carer, must accompany each application (see page 8).

The maximum allocation is $2600 per financial year. More than one application may be lodged within the financial year up to a combined total of $2600. Allocations are provided for a 3 month period. Allocations must be used within the dates specified on your acceptance letter.

Only one service provider can be used per application. If using a respite provider, be aware of the cost of services (day, evening and weekend) before you complete this form. If you decide to change provider a new application will need to be submitted. Please note: Only registered service providers are subject to DHHS safeguarding compliance. If choosing a non-registered service provider you will need to ensure that you understand the implications of this choice. For additional information refer to

Funds are allocated on the basis of availability, priority and program guidelines. Funding is never guaranteed. Funding cannot be allocated retrospectively. Requests for funding frequently exceed the funding available. Not all applications will be successful.

People with National Disability Insurance Scheme (NDIS) funding are ineligible for the program. People who transition to the NDIS while in receipt of Breakaway funding need to be aware that funding will cease the day your plan is approved. For NDIS planning, information and support go to .

Please return the form to:

Email:

Post:Breakaway Flexible Respite Program

PO Box 238 Collins Street West

Melbourne 8007

Breakaway Funding is only available in the Local Government Areas below (Please mark your area)

EASTERN

☐Boroondara ☐Knox ☐Monash ☐Yarra Ranges ☐Maroondah ☐Manningham ☐Whitehorse

SOUTHERN

☐Bayside ☐Kingston ☐Glen Eira ☐Port Phillip ☐Stonnington

GIPPSLAND

☐Bass Coast ☐Baw Baw ☐East Gippsland ☐Latrobe ☐South Gippsland ☐Wellington

Section 1 – About the person with disability

Surname / First Name / Middle Name(s)
Address
Suburb / Postcode
Date of birth / Gender
Does the person with disability…
Live with the carer named on Section 4 of this form)? ☐Yes ☐No
Have a DHHS registration number? (please specify)
Name of School, Day Service, Work Place or Other Service attended?
______
Do you attend ☐Full time? ☐Part time? ☐Not at all?
Are you in receipt of an ISP (Individual Support Package)? ☐Yes ☐No
Have you transitioned to the NDIS (National Disability Insurance Scheme)? ☐Yes ☐No
Receive a Case Management Service? Please specify
☐DHHS ☐Life Assist ☐Care Connect ☐Other
Receive a Flexible Support Package from case management services? ☐Yes ☐No
Display behaviours of concern, such as self-harm, damage to property, aggression?
☐Yes ☐No (if yes, please specify)
Have any medical requirements that would require specific training, such as a peg feed?
☐Yes ☐No (If yes, please specify)
Have a CARS score for autism? Please write the score here:

Section 2-More about the disability

Diagnosis:

PRIMARY DISABILITYSECONDARY DISABILITY

(PLEASE TICK ONE BOX ONLY)(PLEASE TICK AS MANY AS REQUIRED)

☐ / Intellectual / ☐ /
☐ / Physical / ☐ /
☐ / Acquired brain injury (ABI) / ☐
☐ / Deaf/blind – dual disability / ☐
☐ / Vision impaired / ☐
☐ / Hearing impaired / ☐
☐ / Neurological,
including epilepsy and Alzheimer’s / ☐
☐ / Psychiatric / ☐
☐ / Autism, including Asperger’s / ☐

Other, please specify:

What is the individual’s usual residential setting?

☐Private Residence – owned/ purchased☐Private Residence – private rental

☐Private Residence – public rental ☐Private Residence – mobile home/ caravan

☐Boarding House/ Private Hotel☐With Aboriginal Community- temporary shelter

☐Public place/ temporary shelter☐With Aboriginal Community- rented private residence

☐Other – please specify

What is the relationship of the primary carer to the individual?

☐Mother☐Father

☐Wife/Female Partner☐Husband/ Male Partner

☐Daughter☐Son

☐Daughter in-law☐Son-in-law

☐Other female relative☐other male relative

☐Friend/ Neighbour – Female☐Friend/ Neighbour – Male

In which country was the individual born?

☐Australia☐other– Please specify

Is the individual an Australian Citizen? ☐Yes ☐No

Does the individual have Aboriginal or Torres Strait Islander origin?

☐Aboriginal but not TSI origin☐TSI but not Aboriginal origin

☐Both TSI & Aboriginal☐Neither Aboriginal or TSI origin

What is the main language spoken in the individuals home?

☐English☐other– Please specify

Does the individual or carer require interpreter services? ☐No

☐Yes – For spoken language other than English☐Yes – For non spoken communication

What is the individual’s most effective form of communication?

☐Spoken Language☐Sign Language

☐Other effective non-spoken communication☐Little or no effective communication

In line with DHHS regulations, please indicate the support required by the individual in the following areas:(Please mark appropriate response)

Dependent / Needs some assistance / Independent with use of equipment / Independent / Not applicable
Mobility / ☐ / ☐ / ☐ / ☐ / ☐ /
Self-Care / ☐ / ☐ / ☐ / ☐ / ☐ /
Meal Time assistance / ☐ / ☐ / ☐ / ☐ / ☐ /
Communication / ☐ / ☐ / ☐ / ☐ / ☐ /
Interpersonal Relationships / ☐ / ☐ / ☐ / ☐ / ☐ /
Learning/Applying Knowledge/ General Tasks & demands / ☐ / ☐ / ☐ / ☐ / ☐ /
Education / ☐ / ☐ / ☐ / ☐ / ☐ /
Community Access/Economic Life / ☐ / ☐ / ☐ / ☐ / ☐ /
Domestic tasks / ☐ / ☐ / ☐ / ☐ / ☐ /
Employment/Working / ☐ / ☐ / ☐ / ☐ / ☐ /

To what extent does the individual participate in:

(Please mark the box best describing the applicants’ participation regardless required assistance)

Not at all / Partially / Fully / Not known / Not applicable
Getting around outside without transport? / ☐ / ☐ / ☐ / ☐ / ☐ /
Using transport?? / ☐ / ☐ / ☐ / ☐ / ☐ /
Maintaining relationships with family? / ☐ / ☐ / ☐ / ☐ / ☐ /
Maintaining social relationships? / ☐ / ☐ / ☐ / ☐ / ☐ /
Recreation or leisure activities? / ☐ / ☐ / ☐ / ☐ / ☐ /
Working? / ☐ / ☐ / ☐ / ☐ / ☐ /
Handling money? / ☐ / ☐ / ☐ / ☐ / ☐ /

Section 3 - Support currently received

What support is your family currently receiving? Please mark one option for each line

Facility Based Respite / ☐Regular
One weekend per month/ one night per week or more / ☐ Irregular
Once or twice a year / ☐Not at all
Recreation, youth groups,
other social groups / ☐Regular
One weekend per month/ one night per week or more / ☐Irregular
Once or twice a year / ☐Not at all
School holiday Programs/Camps / ☐Regular
Every holiday period / ☐Irregular
Once or twice a year / ☐Not at all
In home support, specific home help per week / ☐9 hours + / ☐5 – 8 hours / ☐1– 4 hours / ☐Nil
Family based respite/Host program / ☐Regular / ☐Not at all
Case management / ☐Regular / ☐None

Section 4 -About the Carer

Surname / First name / Date Of Birth
Address
Suburb / Postcode
Home Phone / Mobile Phone
Postal address (if different to above)
Email address
My preferred communication method is: ☐email ☐mail

Are you a sole carer? ☐Yes☐No

If no, how much does the other carer assist with care?☐Part-time☐Full-time

What is your age group?

☐Under 15 yrs☐15-24 yrs☐25-44yrs☐45-64 yrs☐65yrs and over

How would you describe your general health?

☐Good☐Average☐Poor

Is there more than one person with a disability in the household?

☐No☐Yes – Please specify

Does the primary carer have caring responsibilities to other family members?

(Aged relatives/other children)
☐No☐Yes – Please specify

Section 5 -Application being completed by

(If different from primary carer)

Surname / First name
Phone / Relationship
Email address

Section 6 - About the Respite Activity

What are the dates of the respite you require?

Breakaway Funding Period (All allocations valid for 3 months) / Please tick only ONE box per application / Application to be in by COB
1st Aug – 31st Oct / ☐ / 10th Jul
1st Sep – 30th Nov / ☐ / 10th Aug
1st Oct – 31st Dec / ☐ / 10th Sep
1st Nov – 31st Jan / ☐ / 10th Oct
1st Dec– 28th Feb / ☐ / 10th Nov
1st Jan– 31st Mar / ☐ / 10th Dec
1st Feb – 30th Apr / ☐ / 10th Jan
1st Mar – 31st May / ☐ / 10th Feb
1st Apr – 30th Jun / ☐ / 10th Mar
1st May – 31st Jul / ☐ / 10th Apr
1st Jun – 31st Aug / ☐ / 10th May
1st Jul – 30th Sep / ☐ / 10th Jun

Please Note:

A maximum allocation of $2600 (Ex.GST) per financial year.
Each allocation must be used within 3 month funding period.
More than one application may be lodged within the financial year (Up to $2600 combined total).

What type of funding is being requested?

☐Staff supports ☐Camp ☐Group Activities

Page 1 of 8 / © Yooralla 2014 / Reviewed: 02/0/2017
Document Number: PRIV-00001_Form V4
Staff Support Details
Recreation, holiday program, camp details
Name of agency
Type of activity
Contact person
Phone number
Email
Hours requested
Total funds requested (Ex. GST) / $
Please ensure you know and understand your provider’s costs including weekend and public holiday rates.

Section 7 - Declaration

To be completed by the primary carer or case manager

Breakaway Funding Period
(All allocations valid for 3 months) / Application to be in by COB / Application Processed by / Purchase Order sent to provider by / Letter sent to applicant by
1st August – 31st October / 10th July / 20th July / 25th July / 28th July
1st September – 30th November / 10th Aug / 20th Aug / 25th Aug / 28th Aug
1st October – 31st December / 10th Sept / 20th Sept / 25th Sept / 28th Sept
1st November – 31st January / 10th Oct / 20th Oct / 25th Oct / 28th Oct
1st December – 28th February / 10th Nov / 20th Nov / 25th Nov / 28th Nov
1st January – 31st March / 10th Dec / 20th Dec / 25th Dec / 28th Dec
1st February – 30th April / 10th Jan / 20th Jan / 25th Jan / 28th Jan
1st March – 31st May / 10th Feb / 20th Feb / 25th Feb / 28th Feb
1st April – 30th June / 10th Mar / 20th Mar / 25th Mar / 28th Mar
1st May – 31st July / 10th Apr / 20th Apr / 25th Apr / 28th Apr
1st June – 31st August / 10th May / 20th May / 25th May / 28th May
1st July – 30th September / 10th June / 20th June / 25th June / 28th June

All personal and health information collected will be treated confidentially and will only be used for the purposes of assessing eligibility for this service and service provision.
By signing this form you:

Declare that information you have supplied on this application is correct.
Agree that you have read the above information
Agree that you have read the program guidelines
Understand this is an application for respite funding. Funding is not guaranteed.

Primary Carer Name / Signature / Date

Section 8 –Breakaway Dates

Important:

Authority to Gain/Release
Information
Privacy and Confidentiality /

I/ We ______(print name) authorise Yooralla to obtain written and/or verbal information about me/ ______(print client’s name) from the contacts listed below.

LIST OF PEOPLE / AGENCIES TO BE CONTACTED FOR INFORMATION:

Please tick
()
1. / Health Professionals (GP, hospital, specialists and other health professionals)
2. / Day Placement/School
3. / Family
4. / Department of Human Services/ Case Managers
5. / Previous / Other Service Providers
6.
7.
8.

I / We understand the information gained is to be used for the purpose of

developing and providing individual support / programs
recruitment and staffing
Internal statistical review/collection

Privacy Statement

All personal and health information collected will be treated confidentially and will only be used for the purposes of assisting with the development of a suitable and relevant care plan.

We are also required to release certain statistical information about our service users to the Department of Health and Human Services and Australian Institute of Health and Welfare in order to monitor existing services, plan for future services and for statistical purposes. It is important to note that no directly identifying information such as your name or contact details will be provided to external agencies. There will be no direct consequences in terms of you receiving services should you choose not to consent to de-identified information being released. However, your information would be very useful in assisting to plan better services for you and other people with a disability.

Please indicate consent to non-identifying information being provided to the Department of Health and Human Services and Australian Institute of Health and Welfare for the purposes detailed about.(please tick one)

Yes No

All Yooralla files are internally and externally audited regularly to ensure quality service to you, the consumer. Auditors are

bound by confidentiality agreement.

Please indicate consent for quality review audits. (Please tick one) Yes  No 

Signature:______Date: ______

If you are signing on behalf of client:

Print Your Name:______Relationship to client: ______