Early Childhood Intervention Services Flexible Support Package

Application Form

Please complete this checklist prior to submitting the application.

☐	Read and understood the Important Privacy Information

☐	Completed and signed application form:

Section 1 – Details of the child, parents or guardians, and ECIS professional

Section 2 – ECIS FSP application details

This section must include:

the category of supports being requested

how an ECIS Flexible Support Package links to the current Family Services and Support Plan, and build capacity of the family to address the current and ongoing needs of the child

a proposed expenditure plan with quotes for requested supports and evidence of compliance with Australian safety standards, regulatory and licensing requirements where appropriate.

Section 3 – Declarations and consent

This section must include:

signed parent or guardian declaration and consent

signed ECIS professional declaration

signed managerial declaration

Section 4 – Current Family Services and Support Plan*

This plan must include:

specific goals and actions agreed by the family.

*An Intake Plan must be provided where the child is waiting to receive ECIS.

Is this an application for exceptional circumstances? ☐No	☐Yes

Please ensure that the application form and FSSP are completed. Incomplete applications may result in the documents being returned for completion, this will cause delays in processing the application.

Please refer to the Important Privacy Information on the next page for information on how the details of this application will be used. ECIS professionals assisting families with applications must ensure that they understand the Privacy Declaration.

Early Childhood Intervention Services Flexible Support Package

Privacy information statement

The Department of Education and Early Childhood Development (DEECD) values the privacy of every individual and is committed to protecting all personal and health information collected. In Victoria, the laws that regulate privacy are the Information Privacy Act 2000 and the Health Records Act 2001. These laws regulate how we collect, use, disclose, manage and destroy personal information and health information.

Personal information is “information or an opinion, whether true or not, and whether recorded in a material form or not, about an individual whose identity is apparent, or can reasonably be ascertained from the information or opinion.”

Health information includes information or an opinion about the following:

the physical, mental or psychological health of an individual

the disability of an individual

an individual’s expressed wishes about the provision of services to him or her

personal information that is collected to provide, or in providing, a health service.

Please read this part of the form carefully. If you do not understand any part of this information, please contact the Flexible Support Packages Coordinator.

Collecting personal and health information

The ECIS FSP Regional Assessment Panel collects personal information and health information to assess whether the child is eligible for ECIS FSP and to plan for service delivery by an ECIS FSP Service Provider.

The ECIS FSP Regional Assessment Panel will only collect personal information and health information necessary to assess whether the child is eligible for ECIS and to assist planning for service delivery by ECIS.

The ECIS FSP Regional Assessment Panel collects information by way of this application form and any other supporting documents that may be provided. They may also contact the parent, guardian or carer of the child to collect further information about the child, or to clarify information about the child that has already been provided in the Application Form. On occasions, they may also collect information about the child from other organisations such as other health professionals, other government agencies, or community services organisations.

Examples of personal and health information that ECIS FSP Regional Assessment Panel may collect include:

child’s name and address

name, address and contact details of the parent, guardian or carer of the child

health information relating to the child such as details of the child’s disability or developmental delay

health services that have been provided, or are to be provided to the child.

If the child or family circumstances change, please contact the ECIS FSP Service Provider in your area to advise of the change in information or circumstances.

Using and disclosing personal and health information

ECIS FSP Regional Assessment Panel will use the information provided to determine the child’s eligibility for ECIS FSP and planning for service delivery.

ECIS FSP Service Providers, and DEECD Regional and Central Offices may also use the information provided for research and statistical purposes. In these circumstances, any identifying information about the child or their family is removed to ensure that their personal and health information is protected.

If the child is deemed eligible for ECIS FSP, and the child is referred to an ECIS FSP Service Provider, ECIS FSP Regional Assessment Panel will disclose the child’s personal and health information to the particular Service Provider in order to enable them to provide appropriate services to the child.

Use and disclosure of personal information and health information will otherwise only occur if permitted by law. In some instances, DEECD may be compelled by other laws to disclose information held about the child to other bodies such as a regulatory authority, law enforcement agency, court or tribunal.

Accessing personal and health information

The child or their authorised representative (for example, parent, guardian or carer) can access the personal and health information that is held by DEECD. Such applications can be made to the Information Management Division of the DEECD via email on foi@edumail.vic.gov.au

Storage of personal and health information

The information collected about the child will be stored securely on databases administered by DEECD. Only authorised personnel will have access to the information stored on this database.

Consequences if all or part of the information required is not provided

Withholding information required by ECIS FSP Regional Assessment Panel may delay the processing of the application for ECIS FSP and/or may result in the child being assessed as ineligible for ECIS FSP.

For more information, please refer to the DEECD Privacy Policy which is available at: http://www.education.vic.gov.au/Pages/privacypolicy.aspx

Application Form (please attach additional information)

Section 1 – Details of child, parents or guardians and ECIS professional

Child details

For FSP Coordinator use only:

IRIS identification number OR CRIS identification number:

Date child became involved with ECIS:

Full name of child:

Date of birth:	Age:

Gender: Male ☐ Female ☐	Country of birth:

Street address:

Suburb:	Postcode:

Is the child in or entering Out of Home Care? (E.g., foster care, kinship care) Yes ☐ No ☐

Is the child Aboriginal or Torres Strait Islander? (tick only one box)

Yes, Torres Strait Islander ☐	Yes, Aboriginal ☐

Both Aboriginal and Torres Strait Islander ☐ Neither Aboriginal nor Torres Strait Islander ☐

Please specify the diagnosis of disability or developmental delay:

Names of people completing the application

Name of parent or guardian 1:

Relationship to child:

Street address (if different to the child’s):

Suburb: Postcode:

Local government area:

Country of birth: Language spoken at home:

Is an interpreter required? Yes ☐ No ☐

Does the family receive a carer’s allowance? Yes ☐ No ☐

If no, has a carer’s allowance been applied for?	Yes ☐ No ☐

Phone (home): Mobile: Business:

Email:

Name of parent or guardian 2:

Relationship to child:

Street address (if different to the child’s):

Suburb: Postcode:

Local government area:

Country of birth: Language spoken at home:

Is an interpreter required? Yes ☐ No ☐

Phone (home): Mobile: Business:

Email:

Details of the allocated ECIS professional currently supporting the child and family to complete this application

Name of ECIS professional:

Service/agency name:

Address:

Position title:

Phone:

Email:

Section 2 – ECIS FSP application details

Please provide details as to how this application will support implementation of the Family Services Support Plan.

Please check the box of the ECIS FSP category of supports you are applying for:

(Refer back to the ECIS FSP: A guide for families and ECIS professionals for descriptions of these categories and examples of eligible and ineligible supports.)

Category 1 – Safety risk: physical or psychological ☐

Category 2 – Independence, mobility and functionality ☐

Category 3 – Learning and development ☐

Provide further detail about the identified need.

Describe any:

issues limiting the family’s capacity to address the child’s needs

significant events the child has, or is experiencing that require additional support that cannot be met by other services.

Provide further detail about how the requested supports will assist to build current capacity of the family to support the child.

Provide further detail about how the support will assist to build ongoing capacity of the family to support the child.

Please identify why these goods/services have been selected as the most suitable to address the needs of the child and family.

(Value for money? Fit for purpose? Why this specific type of support?)

What other funding options were explored prior to applying for an ECIS Flexible Support Package?

Level of support/funding currently provided by other programs or services (Please include the type of support, who provides it and the frequency with which it is provided)
☐ State funded Early Childhood Intervention Services
☐ Other early childhood intervention services (including Helping Children with Autism, Better Start)
☐ Home and Community Care (HACC)
☐ Early Choices
☐ Maternal and Child Health Services
☐ Carer Respite
☐ Kindergarten Inclusion Support Services
☐ Other therapy
☐ Childcare
☐ Kindergarten
☐ Family Support Agency
☐ Disability Services Funding (DHS)
☐ Paediatrician
☐ Commonwealth Funded Programs (including Helping Children With Autism)
☐ Other (including Child FIRST and Child Protection)

Has another application been made for ECIS FSP for this or another child in the care of this family or carers? If yes, please provide details.

Child’s name:

Date approved:

Support provided:

Proposed expenditure plan

Please identify details of the support requested in the following expenditure plan.

Note that all nominated providers and associated products must meet Australian standards and regulatory requirements, including relevant licensing requirements. Please attach evidence of compliance with mandatory safety standards, and other regulations and licensing requirements where necessary.

If more than one support or service is being requested, please list in order of priority.

Supports valued at or over $2,500 - Please attach two or more written quotations for supports valued at over $2,500.

Supports valued under $2,500 - Attach two written quotations or documentation providing evidence of actual cost for procurement of goods or services for requests under $2,500. A print out from a supplier website defining all costs and specifications is considered an acceptable form of documentation.

Only one supplier - For any value, one written quotation is appropriate where there is no other supplier of the goods or services (for example, specialised equipment purchased through SWEP).

Supports/Services Requested	Nominated Service Provider Details	Duration (if applicable)	Cost (GST free)	GST
Total amount requested (including delivery and installation costs if applicable)

If this application is successful, who will be the primary contact to support the acquisition of the requested services or supports?

Full name:

Contact telephone number:

Section 3 – Declaration and consent

Privacy notice for parents or guardians and allocated ECIS professionals

Parent or guardian declaration and consent

By signing this form, I declare that to the best of my knowledge this application:

is complete

addresses all relevant requirements as defined in the Early Childhood Intervention Services Flexible Support Packages: Guidelines for families and ECIS Professionals, including relevant Australian standards and regulatory requirements, including relevant licensing requirements where installation is required.

accurately represents the current needs of the child and family.

I accept that the Department of Education and Early Childhood Development (DEECD) has the right to reject this application, or reverse any decision regarding this application.

By signing this form, I declare that I understand the privacy information statement on pages 2 and 3 of this document and the ‘Privacy information for families’ in the Early Childhood Intervention Services Flexible Support Packages: Guidelines for families and ECIS Professionals.

I consent to the use of the personal, health and sensitive information contained within this application form and attached documents for the purposes outlined in the privacy information statement.

I understand that I will be required to cover all costs related to the maintenance repair or replacement of equipment that is purchased, in line with Section 8.2 of the Early Childhood Intervention Services Flexible Support Packages: Guidelines for families and ECIS Professionals.

Parent or guardian’s name:

Postal address:

Email address:

Phone number:

Signature:

Date: ____/_____/_____

Parent or guardian’s name:

Postal address:

Email address:

Phone number:

Signature:

Date: ____/_____/_____

ECIS professional declaration

By signing this form, I declare that to the best of my knowledge this application:

is complete

addresses all relevant requirements as defined in the Early Childhood Intervention Services Flexible Support Packages: A guide for families and ECIS Professionals, including relevant Australian standards and regulatory requirements, including relevant licensing requirements where installation is required.

accurately represents the current needs of the child and family.

I accept that the Department of Education and Early Childhood Development (DEECD) has the right to reject this application, or reverse any decision regarding this application.

By signing this form, I declare that I understand the privacy information statement on pages 2 and 3 of this document and have read the ‘Privacy information for families’ in the Early Childhood Intervention Services Flexible Support Packages: A guide for families and ECIS Professionals. I have ensured that the parents/guardians of the child understand this privacy information.

Allocated ECIS professionals name:

Postal address:

Email address:

Phone number:

Signature:

Date: ____/_____/_____

If you have any concerns about the delivery of the Flexible Support Packages Program, please speak to your allocated ECIS professional or the Flexible Support Packages coordinator as your first step in resolving those issues

Managerial declaration

To be signed by direct line manager of ECIS professional facilitating this application.

I declare that I have reviewed the information contained in the Application Form and Family Services and Support Plan. I recommend this application for consideration by the ECIS FSP Regional Advisory Panel.

Manager’s name:

Signature:

Date: ____/_____/_____

Section 4 – Current Family Service Support Plan

Please attach the current Family Services Support Plan (FSSP) or Intake Plan (where the child is waiting for ECIS) for this child and family.

While there are no specific templates for the development of an FSSP some useful information that you may wish to include are listed below.

Background about the child and family

Goals for the child and family

Current status of these goals

Strategies or actions to achieve the goals

What services or people will assist in achieving the goals

Some areas the goals may cover include, family support (respite, allowances, support groups), and child health (hearing, vision), development (communication skills, behaviour, adaptive equipment) and learning (kindergarten, playgroup)

Where do I send this application? The ECIS professional facilitating this application should send: the completed application form the current FSSP quotes evidence of safety standards and other regulatory requirements plus any other supporting documentation to the ECIS Flexible Support Packages Coordinator responsible for distribution of this support in the local government area of the child’s residence. If you require further detail please contact your Regional office, Department of Education and Early Childhood Development.