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Application For Civic Services

Please read before completion

About this application form

This form is to be used by Civic for people wishing to apply for the following services with Civic:

• Supported Employment — Finding and keeping a job

• School Leaver Employment Supports (SLES)

• Centre Based Activities (Hubs)

• Community and social activities (Groups and Supported Holidays)

Who can apply for Services with Civic?

• A person who is over 18 with a current NDIS plan and applicable funding for the service requested.

• A person who is over 18 but does not have a NDIS plan but may wish to pay directly for the service.

Important information for applicants/support network

• Please complete all sections of this form. It is essential that ALL information is as detailed and accurate as possible to fully assess the support requirements of the applicant.

• The application should be accompanied by documentation that supports statements about the applicant’s support needs, for example behaviour support plans, health care plans and personal care plans.

• Once form is completed, including the signed consent page, please attach any supporting documentation and submit to enquiries@civic.org.au via email wherever possible. If this is not possible, please contact the Customer Experience Team directly to discuss submission.

• A member of the Customer Experience Team may contact the person nominated on the form in (Section 3) if further information is required to support the application.

• Insufficient or inaccurate information may affect the offer of services, including withdrawal of offers made based on inaccurate information provided in the application form.

• Applicants will be contacted by our Customer Experience Team to advise you of the progress of your application and to advise of any necessity to further assess the suitability of the applicant.

• Contact the Customer Experience Team (1300 692 484) if you have any questions regarding this form.

  • SECTION 1: Applicant Information

  • Indigenous Status

  • National Disability Insurance Scheme (NDIS) Plan Status

  • Plan Manager Details (If Applicable)

  • Support Co-ordinator Details (If Applicable)

  • SECTION 2: Person Completing This Form (If Other Than The Applicant)

  • SECTION 3: Nominated Person For Further Clarification/Information

    Note: Member Of The Customer Experience Team May Contact The Person Below If Further Information Is Required

  • SECTION 4: Emergency Contact

  • SECTION 5: About You

  • SECTION 6: Understanding Your Support Needs

  • Communication

  • Behaviour Support

  • Daily Living

    Please indicate the level of support required by the person to undertake the following tasks. Please attach any relevant assessments and or reports.

    No help — you are fully independent. You need no help physically to complete the task

    No help but uses aids — with aids, you can complete the task by yourself with no help

    Prompting — you need reminders or prompting to do the task

    Some support — you need prompting or modelling, and some hand-over-hand support

    Full physical support— you cannot complete the task/activity without full physical support

  • Support Plans

  • Equipment

  • Offending Behaviours

  • SECTION 7: Additional Information For Intake

  • Health

  • Getting Around

    Please refer to any relevant assessments and or reports.

  • SECTION 8: Consent and Declaration

  • You or your authorised representative* must provide consent for the information provided in the Civic Services application (and requested assessments and reports) to be used in the following ways:

    • To create a file (electronic and/or paper)

    • To be shared with direct support workers and their managers for the purposes of providing appropriate support to the applicant.

    • For statistical reporting (information is de-identified).

    *Your representative could be a primary carer, family member, advocate or an appointed guardian. A paid worker such as a case manager or support worker cannot be your representative.

  • Written Consent & Declaration

    I have been informed and consent to the use of information in the application for the Civic Services that I am applying for. I understand that this information may be used to create a file (electronic or paper). I also understand that this consent allows for information in this application to be used for statistical reporting.

  • I declare that I have provided all information relevant to my application for Civic Services and the information given on this form is true and correct to the best of my knowledge.

  • If signed by a representative, please state your relationship to the applicant:

  • Verbal Consent

    Only to be used where it is not practicable to obtain written consent. I have discussed the purpose and disclosure of this information with the applicant or their representative and I am satisfied that they understand how the information will be used, and that they have provided informed consent to the submission of this application for support.

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