APPLICATION FORM FOR MEMBERSHIP OF THE EARLY INTERVENTION SERVICE PROVIDER PANEL UNDER THE 
HELPING CHILDREN WITH AUTISM PACKAGE

Information for Applicants 

If you are completing this application form you should only proceed if you have read the Strategy Guidelines and Operational Guidelines. Assessment of applications will be based on the information provided in these guidelines.
Required Reading

How to
Lodge

Application forms can be completed electronically by email or lodged by post.

Documents specific to your organisation, as requested in this form, can be attached to the email with the application form and/or posted to the address below.

Electronic Submission

Once you have completed all fields on the form and checked the Application Checklist on the last page, you will need to save your completed form and email to FaHCSIA as per the instructions below.

Note: It is recommended to periodically save the Application Form during completion.

1.	Click File > Save As.
2.	Save the form to a location on your computer such as “My Documents”.
3.	When saving the form DO NOT change the file extension.
4.	Open your email software and create a new email.
5.	Enter the subject: HCWA Service Provider Panel Application - <insert your Organisation Name>.
6.	Attach your saved form to the email.
7.	Attach all other documentation as required.  If attachments exceed the email size limit please send a second email with the same subject line.
8.	Send the email to ASD.Support@fahcsia.gov.au

Postal Submission

If submitting by post the application must be signed by the applicant, include the fee schedule and written reference and posted to:

Autism Section
Department of Families, Housing, Community Services and Indigenous Affairs
PO Box 7576
Canberra Business Centre  ACT  2610

Contacts

	Assistance

	After reading the Strategy Guidelines and Operational Guidelines should you have any questions about this application form, please contact ASD Support via email at ASD.Support@fahcsia.gov.au or phone 1800 778 581.

National Relay Service (NRS)

If you are deaf or have a hearing or speech impairment, you can use the NRS to contact any of the Department's listed phone numbers.  To access a 1800 FaHCSIA number NRS users should phone 1800 555 677 or visit the NRS website at http://www.relayservice.com.au/

Personal
Information

Any personal information you provide is protected under the Privacy Act 1988.  The department will not use any personal information for any other purposes unless required by law or you provide your consent to do so. The department will not disclose any personal information to any other organisation or to any individual unless required by law or you provide your consent to do so. 

Information Use

Please note that in some circumstances, FaHCSIA may use successful applicants’ information, other than personal information that has been provided in the applicants’ application, to assist FaHCSIA State Offices to:

(a)	inform staff negotiating and establishing funding agreements of risks and issues which need to be addressed in the agreement for that program; or
(b)	inform future assessments for applications in the same program; or
(c)	inform assessments for applications for other programs.

Please indicate whether you agree to the department using the information (not personal information) you have provided in your application for the purposes listed at (a), (b) and (c) above.

I agree          		
I do not agree		

Part 1		Applicant Details

1	Organisation type and financial status

Is your organisation or lead agency non-government?	 Non Government	 Government      

Is your organisation or lead agency not for profit?		 Not for Profit	 For Profit

2	Organisation entity type

Please select one only from the boxes below.
	
Individual/Sole Trader

Partnership

Trust

Company (incorporated under the Corporations Act 2001)

Incorporated Association

Incorporated Cooperative 

Aboriginal Corporation

Organisation established through specific Commonwealth or State/Territory legislation 		(e.g.universities)
	
If you have not selected any box from the list above, your organisation is not able to apply for funding.	

3	Does your organisation have an Australian Business Number (ABN)? 	
 Yes	 No
If Yes, what is the ABN of your Organisation?	
     	

4	What is the legal name of your organisation?

     	

This is the name that appears on the Australian Business Register at www.business.gov.au.
It may be different to your trading name. All further responses within this Application Form must relate to this entity. This is the legal entity that FaHCSIA will enter into a Standard Funding Agreement with.

5	What is the trading name of your organisation? 
	
     	

This is the name your organisation trades or provides services under, and must be linked with your ABN.

6	What is your organisation’s physical address? (Not a PO Box)

Enter the contact person’s address if your organisation does not have its own registered address.
	
Building / Floor	     	
	
Street No. and name	     	
	
Suburb / Town	     		
	
State	     	Postcode	     		

7	What is the postal address your organisation?				Same as above  
	
Building / Floor	     	
	
Street No. and name	     	
	
Suburb / Town	     		
	
State	     	Postcode	     		

8	 What is the outlet name, where the service will be delivered? (If different, to Q4 or Q5.)

     	

9a	What is the outlet’s physical address? (Not a PO Box)

Location #1	
Building / Floor	     	
	
Street No. and name	     	
	
Suburb / Town	     		
	
State	     	Postcode	     		

9b		If more than one outlet is going to be used to deliver the service please list the 	location/s below.

Enter the contact person’s address if your organisation does not have its own registered address, etc.

Location #2	
Building / Floor	     	
	
Street No. and name	     	
	
Suburb / Town	     		
	
State	     	Postcode	     		
	
Location #3	
Building / Floor	     	
	
Street No. and name	     	
	
Suburb / Town	     		
	
State	     	Postcode	     		

10	Who are the authorised Contact Persons for this application?

Please note: To process claims for payment through FaHCSIA's Online Funding Management System (FOFMS), you will require a minimum of two users with FOFMS access.

	Preferred Contact	Alternative Contact	
Title	     	     	
First name	     	     	
Surname	     	     	
Position in Organisation	     	     	
Telephone number	     	     	
Mobile number	     	     	
Fax number	     	     	
Business Email address	     	     	

Part 2	Financial Details

FaHCSIA is unable to facilitate the transfer of funds to your organisation 
if you do not provide bank account details.

11	Is your organisation or lead agency registered for GST?	  Yes              No

Questions on GST requirements should be addressed to the Australian Taxation Office.

12	If you would like Recipient Created Tax Invoices (RCTI’s) to be sent to an alternative email address to that of the “Preferred Contact” listed in Q10, please provide the new email address here.

     	

13	Please provide details of the bank account for payment should your application be successful.

Record the account details of the organisation listed at Q4 only. FaHCSIA will not make cheque payments or payments to a third party.

Institution/Branch	     	
BSB Number	     	
Account Number	     	
Account Name	     	

14a	Has your organisation (or any member in the case of a consortium) recently applied for or been approved for Better Start?					
Yes		 No

14b	Has your organisation (or any member in the case of a consortium) recently applied for any other FaHCSIA funding?		
Yes (please list)	No

FaHCSIA program name
	
Amount of funding	
Period of funding	
Date of application	
     	     	     	     	
     	     	     	     	
     	     	     	     	

Part 3	Service Delivery Details

15	Please indicate if the applicant has the following:

	YES	NO	
Complaints handling policies and procedures			
Records management policies and procedures			
Risk management plan			
Financial policy and procedures			

As a part of our verification process you may be asked to provide copies of these documents within 10 days of a request.

16	Please select any of the following applicable to your organisation. 

	YES	NO	
•	Any form of litigation or enquiry during the past three years, current or pending.
NOTE: If you have settled a claim on confidential terms, please provide details below.
			
•	Any significant financial matter which may impact on the organisation, 
E.g. insolvency or voluntary administration.
			
•	Future commitments or contingent liabilities that might materially affect the organisation.
			
If you have selected any of the above (Q18) please provide a short explanation here.  
(Further information may be requested.)

     

	

17	Does your organisation plan to sub-contract any or all of the service provision, if this application is successful?
Yes		No
If yes, successful applicants will be asked to provide details of those sub-contracting arrangements and the organisations involved.

18	Does the applicant plan to deliver services as part of a consortium? Yes		No

If yes, complete the table below. If no, continue on to Part 4.

Consortium Definitions
•	Lead Agency – This is the legal entity, specified in Part 2, which if successful will be invited to enter into a Standard Funding Agreement with FaHCSIA.

•	Consortium – This is the combined group of entities that is applying for funding through this application form.
Note: The consortium does not sign a Standard Funding Agreement with FaHCSIA.

Consortium Details		
Please list the legal names of all members of the Consortium and provide a brief description of each member’s role in the delivery of the services.
Attach a Memorandum of Understanding signed by the proposed Consortium members showing:
•	their agreement to enter into a Consortium arrangement;
•	the nature of the legal relationship between parties; and
•	how the arrangements between the members will be managed and overseen by the Lead Agency.
An overall assessment of a Consortium will be made based on the assessment of each member organisation.
The Department will not accept changes to Consortium arrangements that, in the opinion of the Department, represent a material change to this Application.

Organisation Legal Name	Organisation
Trading Name	ABN Number	Entity Type	Physical Street Address	Telephone
Number	Type of Intervention Offered	
     

	     	     	     	     	     	     	
     

	     	     	     	     	     	     	
     

	     	     	     	     	     	     	
     

	     	     	     	     	     	     	
     

	     	     	     	     	     	     	
     

	     	     	     	     	     	     	
     
	     	     	     	     	     	     	

Part 4 	Responses to Determine Eligibility to join the Helping Children with Autism Early Intervention Service Provider Panel.

Important Information for Applicants
•	Eligible applications will be assessed according to how strongly they meet the selection criteria.
•	Applicants must meet all of the selection criteria to a satisfactory degree in order to be considered for inclusion on the Panel.
•	Applicants not meeting Selection Criterion 1 to a satisfactory degree will be excluded from the remainder of the selection process and will therefore not be eligible for inclusion on the Panel.  
•	Provided Selection Criterion 1 is met to a satisfactory degree, all selection criteria will contribute to the assessment process. Selection Criterion 2, 3 and 4, will contribute equally. Selection Criterion 5 will be assessed to determine the additional capacity of the applicant.
•	Your response to the selection criteria must not exceed 15 pages in total (material in response to the selection criteria that exceed this limit will not be considered in the assessment process).
•	Applicants must provide one written reference (including name and contact details) in support of their application, as well as the names and contact details of an additional referee (one referee must be specific to Criterion 5).  

Criterion 1
Demonstrated experience, expertise and capacity in delivering the evidence-based multidisciplinary early intervention services listed below to children aged 0-6 years diagnosed with an ASD. 
 
For this response, please provide a comprehensive outline of the early intervention services you will provide against one or more of the following eligible interventions:

•	Behavioural interventions – application of learning theory and skill development;
•	Developmental and social learning interventions – building relationships and development of social emotional capacities;
•	Therapy-based interventions – communication and social development or sensory motor development; and/or
•	Family-based interventions – working with families to develop skills in working with their children.

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

     

Criterion 2
Demonstrated ability to meet the planned outcomes of the early intervention component of the Helping Children with Autism package. 

For this response, you will need to consider whether your services will: 

•	Increase access to early intervention for children aged 0-6 years diagnosed with an ASD;
•	Improve the overall wellbeing of eligible children; 
•	Improve strategies and skills of parents and carers to meet the needs of eligible children; and
•	Improve the capability of eligible children to attend formal school and participate in everyday life.

     	

Criterion 3
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; and
•	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.

Note: The applicant will be required to complete the fee schedule template, which will be made public through the FaHCSIA website if your application is found to be successful.

     	

Criterion 4
Demonstrated competence to deliver early intervention services to children aged 0-6 years with an ASD, their families and carers through the Helping Children with Autism package. 
 
For this response, we would like you to consider:

•	The skills and qualifications of people including information about the: 
•	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 and have the knowledge and skills required for their special needs;
•	Names of staff who are registered, certified or licenced through a professional association to deliver services to children 0-6 years with ASD; and
•	Details of professional affiliations.

In addition, you should demonstrate:

• Your capacity to provide, if required, training, support and professional supervision to undergraduates and post graduate students.

Eligibility Criteria for Sole Providers

•	Occupational Therapists in Queensland, Western Australia, South Australia and the Northern Territory must be registered with the Occupational Therapists Board in the State or Territory in which they are practising; in other States and the Australian Capital Territory, they must be a ‘Full-time Member’ or ‘Part-time Member’ of OT AUSTRALIA, the national body of the Australian Association of Occupational Therapists.  

•	Psychologists must be registered, without limitation, with the Psychologists Registration Board in the State or Territory in which they are practising.  Psychologists must identify themselves as providers of Autism services and be on the APS Autism and PDD Identified Practitioners List

•	Speech Pathologists must be a Certified Practising Speech Pathologist (under Speech Pathology Australia’s Professional Self Regulation program).  Speech Pathologists practising in Queensland must be registered with the Speech Pathologist Board of Queensland. In all other States, the Australian Capital Territory and the Northern Territory, you must be a ‘Practising Member’ of Speech Pathology Australia.  

     
	
Criterion 5
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. 

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. 

     	
Part 5	Referee Contact Details
Please provide the name and contact details of 2 referees, one verbal and one written.

Referee 1 - verbal	
Title	     	Full Name	     	
Name of Organisation	     	
Position in Organisation	     	
Telephone Number	     	Mobile Number	     	
Fax Number	     	
Business Email Address	     	

Referee 2 - written	
Title	     	Full Name	     	
Name of Organisation	     	
Position in Organisation	     	
Telephone Number	     	Mobile Number	     	
Fax Number	     	
Business Email Address	     	

Written Reference (Approx 350 words)
     	

Part 6				Declaration

I declare that:
•	the information, including financial information, contained in this form is true and accurate;
•	I have read the Strategy Guidelines and Operational Guidelines;
•	I have read, understood and accept the terms and conditions of funding and my organisation will be able to fully comply with those conditions;
•	I understand that incomplete applications may not be considered;
•	consortium members (if applicable) will be those specified in the Application: from the time the Application is received by the Department, and through assessment and any Standard Funding Agreement negotiations;
•	if a consortium is used and there is any change to its composition, I will notify the department prior to signing any Standard Funding Agreement;
•	consortium members (if applicable) have given permission for their organisation’s information to be made available to the department;
•	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.
	
Signature		Date	
     		     	
Name (please print)		Position in your Organisation	
     		     	

NOTE: Applications being submitted by post must be signed.	

Standard Funding Agreement
Successful applicants must agree to and sign a Standard Funding Agreement with the Australian Government Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA).  

The related Terms and Conditions are available via the website at www.fahcsia.gov.au/autism

	If this form was completed by an organisation with less than 20 employees, please provide an estimate of the time taken to complete this form.
Include:
•	The time actually spent reading the instructions, working on the questions and obtaining the information.
•	The time spent by all employees in collecting and providing this information.
	
		     	Hours	     	Minutes	

Part 7  				Application Checklist 

To ensure that your application is complete, use the following checklist.

Part 1	Applicant Details: Completed		
Part 2	Financial Details: Completed          		
Part 3	Service Delivery Details: Consortium members and roles listed(if applicable?)
•	Memorandum of Understanding attached, signed by members?
All questions completed?		
Part 4	Responses to Selection Criteria:  
Have you addressed selection criteria 1 to 5 in this Application?		
Part 5 	Referee Contact Details 
•	Referee details included ?
•	Written reference included ?		
Part 6	Declaration: Have you read and completed the declaration carefully?		
Part 7	Application Checklist (this part): Have you completed the application checklist?		

Note: Applications that are incomplete may not be considered.