AustralianGovernment

DepartmentofFamilies,Housing, CommunityServicesandIndigenousAffairs

Application Form

FORMEMBERSHIPOFTHEEARLYINTERVENTIONSERVICEPROVIDERPANELFOR: THEBETTERSTARTFORCHILDRENWITHDISABILITYINITIATIVEAND/ORHELPINGCHILDRENWITHAUTISMPACKAGE

FaHCSIAhasestablished apanelofserviceproviderstodeliverearlyinterventionservicestoeligiblechildrenaspartof theBetterStartforChildrenwithDisabilityinitiative(BetterStart)andHelpingChildrenwithAutismpackage(HCWA).The aimoftheEarlyInterventionServiceProviderpanelistoimproveaccesstotargetedandappropriateearlyintervention servicesforeligiblechildren.

Organisations, consortiaorsoleproviderscanapplytojointheBetterStartandHCWAEarlyInterventionService Providerpanels.Pleasenotethatforthepurposeofthisapplicationform,theterm'applicant'includesorganisation, consortiumandsoleprovider.

Open/Closing Date

How toLodge

ProgramGuidelines

QuestionsandAnswers

NationalRelayService

PersonalInformation

UseofInformation

Youcanapplytojointheserviceproviderpanelatanytime.Assessmentof applicationsisongoingandyouwillbe contacted afteryourapplicationhasbeen assessed. Assessmentisusuallycompletedwithin8weeksoflodgingyour application.

Allcompletedapplicationformsmustbesubmittedelectronically. Directionsfor electronicsubmissionareprovidedattheendofthisform.Ifyouareunableto submityourapplicationelectronically, pleasecontacttheEarlyInterventionHelpdesk on1800778581oremail

rBetterStartenquiries,or

rHCWAenquiries.

Beforecommencingthisapplication,youmustreadthefollowing:

  • EarlyInterventionServicesforChildrenwithDisabilityProgramGuidelinesPartA; EarlyInterventionServicesforChildrenwithDisabilityProgramGuidelinesPartB; EarlyInterventionServicesforChildrenwithDisabilityProgramGuidelinesPartC; BetterStartforChildrenwithDisabilityEarlyInterventionServiceProviderPanel OperationalGuidelines;and/or
  • HelpingChildrenwithAutismEarlyInterventionServiceProviderPanelOperational
  • Guidelines.

ThesedocumentsarelocatedontheFaHCSIAwebsite:

ApplicationsforMembershipoftheEarlyInterventionServiceProviderPanel

If youhaveanyquestionsaboutthisapplicationform,pleaserefertotheOperational Guidelinesfortheprogramyourquestionrelatesto.If youcannotfindtheinformation yourequirepleasecontacttheEarlyInterventionHelpdesk(detailsabove).

If youaredeaforhaveahearingorspeechimpairment, youcanusetheNRSto accessanyoftheDepartment'slistedphonenumbers.Toaccessa 1800FaHCSIA numberyoushouldphone1800555727(speakandlisten)or1800555677(TTY)or visit

AnypersonalinformationyouprovideisprotectedunderthePrivacyAct1988.The departmentwillnotuseanypersonalinformationforanyotherpurposesunless requiredbylaworyouprovideyourconsenttodoso.Thedepartmentwillnotdisclose anypersonalinformationtoanyotherorganisationortoanyindividualunlessrequired bylaworyouprovideyourconsenttodoso.

PleasenotethatFaHCSIAmayusesuccessfulapplicants'information,otherthan personalinformationthathasbeenprovidedintheapplicants’ application,toassist FaHCSIAto:

(a)complywiththeAustralianGovernment requirementtopublishthenamesofall fundingrecipientsontheFaHCSIAwebsite

(b)informstaffnegotiatingandestablishingfundingagreementsofrisksandissues whichneedtobeaddressedintheagreementforthatprogram,and/or

(c)informfutureassessmentsforapplications.

Youcanonlyapplyifyouagreetothedepartmentusingtheinformation(notpersonal information)youhaveprovidedinyourapplicationforthepurposeslistedat(a),(b) and(c)above.

Iagree

Part 1 Application Type

1Selectwhichpanelyourapplication refersto:

BetterStartforChildrenwithDisabilityinitiative(BetterStart)

HelpingChildrenwithAutismpackage(HCWA)

BothBetterStartandHCWApanels

Part2ApplicantDetails

2Whatistheapplicant'slegalentitytype?

3Istheapplicantnot-for-profit?

NoYes

4Whatisthelegalnameoftheapplicant?

5Does this applicant have a trading name that is different to the legal name?

NoYes (please specify)

Tradingname ______

6Whatisthephysicalbusinessaddressandmaincontactdetailsoftheapplicant?

Floor/Street Number ______

Street NameandType ______

State______Postcode ______

Main telephone ______Main email address ______

Web address______

7Whatisthepostaladdressofyourorganisation?

PostalAddressSameasbusinessaddressabove

If not, please complete:

FloorIBuilding ______

Street Name ______

Suburb I Town______

State ______Postcode ______

8Who is the preferred authorised contact person for this application?

Title ______

First name ______

Last name ______

Position in organisation______

other (please specify)______

Telephone ______Mobile______Email address ______

9Who is the alternate contact?

Title ______

First name ______

Position in organisation______

other, please specify ______

Telephone ______Mobile ______

Email address ______

Part3FinancialDetails

10Does theapplicanthave an Australian Business Number (ABN)?

NoYes

11Is the applicant GST registered?

NoYes

12Providedetailsofyour bankaccounttobeusedforpayment

BSB Number ______Account Number ______

AccountName ______

13 Providethe emailaddress forpaymentadvicetobesentto

Emailaddress ______

Part4ServiceDeliveryDetails

14Doyouplantodeliverservicesaspart ofa consortium?

NoYes

15Doyouplantosub-contractanyservices?

NoYes

16Haveyourconsortiumorstaffbeenthesubject of anyformoflitigationorenquiryduring thepast three yearscurrentorpending?

NOTE:Ifyouhavesettledaclaimonconfidentialterms,pleaseindicatethisintheresponse.

NoYes (pleaseprovideashortexplanation)

17Doestheapplicanthavethefollowingpolicies/proceduresinplace?

Weunderstandthatsmallbusinessesand soleprovidersdonottypicallyneed todevelopfullwrittenplansasthe proceduresareknowntoeveryone.However,forauditpurposes,werequirethatashortwrittendescriptionof thesepoliciesiskeptonfile.

NoYesComplaintshandlingpolicies andprocedures

NoYesRecordsmanagement policies andprocedures

NoYesRiskmanagementplan

NoYes Financialpolicy andprocedures

Pleasenote,aspartofourverificationprocessyoumaybeaskedtoprovidecopiesofthedocuments outlinedabovewithin10workingdaysofarequest.

Part5SelectionCriteriaforPanelMembership

Important Information for applicants

Applicants will be eligible for membership of the Early Intervention Service Provider Panel if they meet the criteria listed below. Please provide sufficient detail to assist us in determining your eligibility to join the service provider panel. If you are applying for membership of both the HCWA and Better Start Service Provider Panels, you will note there are separate criteria under 1 and 2 which will need to be addressed for each program. The remaining criteria are the same for both programs.

Criterion1: Better Start- Applicants applying for Better Start or Both

18Outlineyourrelevantexperienceindeliveringearlyinterventionservicestochildrenaged0-6whohave beendiagnosedwithadisabilityandassessedaseligibleforearlyinterventionfundingundertheBetter Startinitiative.

19 Please list the services/interventions you propose to provide under the Better Start for Children withDisability Early Intervention Service Provider Panel.

Criterion 2: Better Start- Applicants applying for Better Start or Both

20Complete and attach the Better Start fee schedule template available on the Fahcsia website

Fee schedules are published on the Department's website to assist parents and carers to locate service providers in their area and make informed decisions about value for money.

Note: Instructions for attaching the fee schedule are included in the fee schedule document

Please attach a completed Better Start fee schedule to this document.

Pleaseprovideanoutlinefordeveloping,monitoringandassessinganinterventionplanforeligible children.

Criterion 1 HCWA -Applicants applying for HCWA or Both

22Outlineyourrelevantexperience,expertiseandcapacityindeliveringevidence-basedmultidisciplinary earlyinterventionservicestochildrenaged0-6yearsdiagnosedwithanASD.

23Provideacomprehensiveoutlineofthe earlyinterventionservicesyouwillprovidewithinoneormoreof theearlyinterventiondomains:

  • language and communication development
  • social development andinteraction
  • repetitive behaviour and/or restricted interests

This response should also describe how you intend to deliver services using a multidisciplinary ortransdisciplinarycollaborative approach.

Note: The only interventions eligible for inclusion on the Panel are those outlined in the Operational Guidelines.

Criterion 2 HCWA - Applicants applying for HCWA or Both

24CompleteandattachtheHCWAfeescheduletemplateavailableat

ApplicationsforMembershipoftheEarlyInterventionServiceProviderPanel

Fee schedules are published on the Department's website to assist parents and carers to locate service providers in their area and make informed decisions about value for money.

Note: Instructions for attaching the fee schedule are included in the fee schedule document

AttachcompletedHCWAfeeschedule to this application

25Provide evidence that the planned early interventions represent value for money for the families and carers of children aged 0-6 years diagnosed with an ASD.

For this response, you should include:

-your proposed interventions and the associated schedule of fees;

-your proposed assessment of the social, cognitive and adaptive functioning of eligible children before, during and at the end of their treatment plan.

In addition, you should demonstrate the value, quality and quantity of your early intervention service

Criterion1-AllApplicants

26 Provide information about how your early intervention services contribute to improved wellbeing for eligible children.

27 Provide information about how your early intervention services contribute to improved strategies and skills of parents/carers.

28 Provide information about how your early intervention services contribute to improved capacity of eligible children to transition to an educational setting and participate in everyday life.

Criterion 2 -All Applicants

29 Eligibility Requirements for Professional Practitioners

Please refer to the Operational Guidelines for details of eligibility requirements for professionals delivering early intervention services under HCWA and Better Start.

Please identify all early intervention professionals who will be delivering services (include details for all consortium members and sub-contractors):

Earlyintervention professionals / Detailof other / No of professionals
Total

30 Staffing Profile

Provide details of professional qualifications and other relevant experience for staff delivering early intervention services to eligible children, their families and carers, including a description of roles and responsibilities for all positions.

The response should include:

- Names and qualifications of staff who will deliver early intervention services;

- Names of staff who have been specifically trained in working with children with ASD or relevant Better Start disability and have the knowledge and skills required for their special needs;

- Names of staff who are registered, certified or licensed through a professional association to deliver services to children 0-6 years with ASD or relevant Better Start disability; and

- Details of professional affiliations.

Criterion 3 -All Applicants

31 Demonstrated experience, expertise or capacity to deliver early intervention services to children aged 0-6 years from Indigenous or culturally and linguistically diverse (CALD) backgrounds, and/or from rural or remote areas, who have been diagnosed with an ASD or eligible Better Start disability.

For this response, we would like you to consider:

- stakeholder consultation and engagement;

- strategies employed and the outcomes achieved; and

- partnerships with specialised providers and community based allied health service professionals.

Applicants must also provide the name and contact details of at least one referee specific to this criterion.

Part6RefereeContactDetails

Please provide the name and contact details of two professional referees who can support the claims made against the selection criteria.

One written reference (of no more than 350 words) must be provided in this application.

Referee1-Verbal

Title______FullName ______

Nameof

Organisation ______

Positionin

Organisation ______

Telephone______Fax______

Business Email Address______

Referee2-Written

Title______FullName___________

Nameof

Organisation______

Positionin

Organisation______MobileNumber______

Telephone______Fax______

Business Email Address______

Please attachedreferenceto this application.

Part7Declaration

32Readandcompletethefollowingdeclaration.

I declare that:

  • The information, contained in this form is true and accurate
  • I have read, understood and agree to abide by the Program Guidelines and Operational Guidelines
  • I have read, understood and agree to the Standard Funding Agreement Terms and Conditions, should this application be successful
  • The organisation making this application is an eligible organisation as described in the Program Guidelines
  • I understand that incomplete applications may not be considered
  • I agree to receiving a Recipient Created Tax Invoice (RCTI) for this funding if this application is successful
  • If and where any personal details of a third party are included, the third party has been made aware of, and given their permission for, those details to appear in this application
  • I give consent to the Department of Families, Housing, Community Services and Indigenous Affairs to make public the details of my organisation and the funding received, if my organisation is successful.

Iunderstandandagreetotheabove:

FullnameofAuthorisingOfficerPositioninOrganisationDate

______/____/_____

Part8ApplicationSubmission

Submission

To submit this form to the Department please:

  1. Ensure all responses are true and accurate.
  2. Email the completed form to .
  3. Upon successful submission you will be issued with a receipt.