Specialist Supported Living Services
Application Form
(Please send with your application)
1. Client details
Date completed: / CIS ID: /Name: /
Date of Birth: / Age: /
Address: /
Person Responsible: /
Person Responsible Phone Contact: /
Please specify:
☐ Aboriginal or Torres Strait Islander
☐ CALD background
☐ Lives in Specialised Disability Accommodation (SDA)
☐ Lives in a Large Residential Centre (LRC)
☐ Uses a respite service
☐ Lives with relatives/guardian without support
☐ Lives with relatives/guardian with support
☐ Has NDIS funding /
2. Details of person completing application form
Your Name: District/Residences:
Your Phone: Relationship to client:
3. What type of service are you requesting?
☐ Ageing
☐ Behaviour
☐ Health
4. Are you requesting a service in a specific geographic area?
☐ No
☐ Yes
If yes, please specify:
5. Rationale for each eligibility criteria
A rationale in support of the application demonstrating how the applicant meets each eligibility criteria as set out in the Specialist Supported Living Services - Eligibility and Access Guidelines must be completed.
Criteria No. / Criteria /1 / The person, their family or those speaking on their behalf have expressed a desire to live in a SSL service model to enable their complex supports needs to be effectively managed and acknowledge that this is a very intensive model of service.
[Enter response here] /
2 / The person is eligible for Specialist Disability Accommodation, if not already receiving Specialist Disability Accommodation.
[Enter response here] /
3 / The person presents with significant behaviours of concern and/or mental health needs; or multiple health needs that have a cumulative impact on their health and wellbeing. The kind of issues to show evidence of are:
· The person’s quality of life, or ability to cope in their current placement, has significantly decreased over a period of time or has the potential to do so.
· The nature of the complex support needs has had significant and negative impact on themselves and/or others, and they are at very high risk of experiencing an acute event due to complex support needs.
· There is a demonstrated need for a more support-intensive environment to meet their complex support needs.
[Enter response here] /
4 / The person’s current placement is unable to meet their complex support needs. The person experiences multiple gaps in their care and requires a higher level of clinical/nursing support than is available in their current environment.
[Enter response here] /
5 / Current service or place of residence has been continually unable to make progress towards identified health requirements, or positive behaviour support programming, or effectively support the person in their current supported accommodation setting. If available, evidence of prior strategies should be attached e.g. Client Monitoring & Review System (CMRS).
[Enter response here] /
6. Information to support the application
Please list all supporting documents attached to this application in the table below. Please refer to the SSL Eligibility and Access Guidelines for examples of potential documents.
Ageing / Behaviour / Health /Observed signs of Ageing Checklist / ☐ Attached
☐ N/A / Behaviour Assessment Report / ☐ Attached
☐ N/A / Comprehensive Health Assessment Program / ☐ Attached
☐ N/A /
Broad Screen Checklist of Observed Changes for Adults with Intellectual Disability / ☐ Attached
☐ N/A / Multi Element Behaviour Support Plan / ☐ Attached
☐ N/A / Nasogastric Nutrition/Gastronomy Mealtime Plan / ☐ Attached
☐ N/A /
Evidence of Observed Signs of Ageing Form / ☐ Attached
☐ N/A / Incident Prevention & Response Plan / ☐ Attached
☐ N/A / My Safety Plan / ☐ Attached
☐ N/A /
Advanced Aged-Related Needs Form / ☐ Attached
☐ N/A / Restricted Practice Authorisation Details / ☐ Attached
☐ N/A / My Health and Wellbeing Plan / ☐ Attached
☐ N/A /
Specialist report evidencing a diagnosis of Dementia / ☐ Attached
☐ N/A / Longitudinal Behavioural Data Summary & Commentary / ☐ Attached
☐ N/A / Manual Handling Plan / ☐ Attached
☐ N/A /
ACAP Assessment (if over 65 years old) / ☐ Attached
☐ N/A / Behaviour Support Plan / ☐ Attached
☐ N/A /
For all other supporting documentation attached to this application, please provide a description for each document in the table below.
No. / Document /1 / One page document describing current living environment and summary of health and physical abilities. Please attach a photo. / ☒ Attached
☐ N/A /
2 / ☐ Attached
☐ N/A /
3 / ☐ Attached
☐ N/A /
4 / ☐ Attached
☐ N/A /
5 / ☐ Attached
☐ N/A /
6 / ☐ Attached
☐ N/A /
7 / ☐ Attached
☐ N/A /
8 / ☐ Attached
☐ N/A /
9 / ☐ Attached
☐ N/A /
10 / ☐ Attached
☐ N/A /
11 / ☐ Attached
☐ N/A /
12 / ☐ Attached
☐ N/A /
13 / ☐ Attached
☐ N/A /
14 / ☐ Attached
☐ N/A /
15 / ☐ Attached
☐ N/A /
7. Endorsement of the application
A – Approval from Family, Guardian, or Person Responsible endorsing application /I support this application for [PLEASE ENTER CLIENT NAME] for placement within a SSL service. /
Person supporting
Application: / Signature: /
Relationship to
Applicant: / Phone: /
Preferred Correspondence Address
(mail/email) /
B - Details of the Manager endorsing this application /
I endorse this application and verify that all the required documentation is attached to support this application and that the person meets the eligibility criteria and no other accommodation options are available for the person. /
Manager’s Name/
Signature: / District: /
Position Title: / Phone: /
C - If this referral is being made by:
· District- the application should be endorsed by the Director Disability, OR
· LRCSSL- the application should be endorsed by the Director LRC or Director SSL, OR
· NGO- the application should be endorsed by the Family, Guardian, or Person Responsible. /
I endorse the submission of this application to the SSL Eligibility and Allocation Committee and verify that all the required documentation is attached to support this application and that no other accommodation options are available for the person. /
Name/
Signature: / District/SSL/LRC/
NGO: /
Position Title: / Phone: /
8. Consent to register and share information
You or your decision maker must provide consent for the application, and information provided in the application, to be used in the following ways:
· to create a file (electronic and/or paper)
· to make a decision about possible placement in a SSL service
· seen by external people when making decisions about allocating funding or a vacancy
· for statistical reporting
· to help set up a support you have been allocated, including external service providers
Written Consent /I have been informed and consent to the use of information in this application for the purposes of determining placement in a SSL service. I understand that this information may also be used in consideration and allocation of supports, and provided to external agencies for this purpose. I also understand that this consent allows for information in this application to be used for statistical reporting purposes. /
Signed: / Name: / Date: /
Is the signee the decision maker?
☐ Yes
☐ No
If no, please specify relationship to the applicant: /
Spoken/signing[1] consent
(only to be used where it is not practicable to obtain written consent and witnessed where possible) /
I have discussed the purpose and disclosure of this information with the applicant or their decision maker and am satisfied that they understand how the information will be used, and that they have provided informed consent to the submission of this application. /
Spoken/signing consent provided to: / Signature: /
Details regarding consent: / Date: /
Relationship to the person with disability: /
[1] Signing refers to use of a signing communication system or augmented communication device or tools.