Flexible Support Application

Privacy declaration

Information collected in this application will be used by Latrobe City Council’s Aged and Disability Services to assess the application for a Flexible Support Package.  Following endorsement of the application, the information requested in this form will also be used to assist with the administration of the Flexible Support Package. The applicant’s identity will be protected during this process.

If you have any queries about the information requested, please contact Latrobe City Council’s Aged and Disability Services on 1300 367 700.

Flexible support package application form

To apply for a flexible support package please complete the form below and submit or print the Flexible support package application form(DOCX, 96KB) and post to Latrobe City Council, Flexible Support Program, PO BOX 264, Morwell 3840 or fax 5128 5673 or email Disabilityplanning@latrobe.vic.gov.au

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APPLICANT'S DETAILS
Gender

Aboriginal or Torres Strait Islander status * (required)



Is an interpreter required? * (required)

Does the applicant have a disability defined by the Disability Act 2006? * (required)

Is the applicant in receipt of a Disability Support Pension? * (required)

Does the applicant have case management? * (required)

Does the applicant receive funding from Workcover, TAC or DVA for their primary disability? * (required)

Family Details
FAMILY CONTACT DETAILS
Does the family receive a carer's allowance/payment?

REFERRER'S DETAILS
SUPPORT PLAN
SUPPORT PLAN GOAL 1
SUPPORT PLAN GOAL 2
SUPPORT PLAN GOAL 3
Agreement
Latrobe City Council is regularly audited to ensure best practice in the provision of services to people with a disability. To assist with the process, auditors look at a random selection of paperwork to determine if agreed processes have been followed. Clients cannot be identified by this process.
Do you agree to auditors consulting this application as part of their process?

 

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