<p>Application for Synapse Brokerage Program Funds</p><p>The aim of the Brokerage program is to assist people living in NSW who have a brain injury to achieve an aspiration or goal that is not otherwise able to be funded. Your intention may be to enhance your quality life in some way through the purchase of goods or services that will be enabling or beneficial for you.</p><p>Please ensure that you read the corresponding guidelines before you complete this form. Applications that are not completed correctly will be returned and this may delay your application considerably.</p><p>Section 1- Personal details</p><p>Name of applicant </p><p>Home address of applicant</p><p>Street Address</p><p>Suburb/Town Postcode</p><p>Date of Birth: / / Gender: M  F (Please tick)</p><p>Are you of Aboriginal or Torres Strait Islander origin? Yes  No  (Please tick)</p><p>Cultural identity: Nationality:</p><p>Language spoken at home:</p><p>Brief description of your living arrangements: (e.g. live independently, with family, group home)</p><p>What is your preferred method of communication with us? Please tick </p><p> Phone  Email  Letter  Text message  Via Support person </p><p> Other (Please specify)………………………………………………………………</p><p>Home phone number: Mobile phone number: </p><p>Email address: </p><p>Are you currently a Friend of Synapse? Yes  No  (Please tick)</p><p>If no, would you like to become a Friend of Synapse (receive biannual magazine Bridge and newsletters) Yes  No  (Please tick) Section 2:</p><p>Is someone (e.g. carer / family member) supporting you to prepare this application?</p><p>Name of support person, if applicable</p><p>What is your relationship with them?</p><p>Do you agree to Synapse sharing information about this application with this person?</p><p>Pease tick as appropriate Yes  No  </p><p>Contact details of support person </p><p>Postal address</p><p>Street</p><p>Suburb/Town Postcode</p><p>Phone number(s)</p><p>Email address</p><p>Are you supported by a community service or professional (e.g. case manager, allied health provider) who is involved in developing and supporting this plan? </p><p>Name of staff member</p><p>Job title</p><p>Organisation</p><p>Do you agree to Synapse sharing information about this application with this person / agency? </p><p>Please tick as appropriate Yes  No  </p><p>Phone number</p><p>Email address</p><p>Who will be the primary contact person for this application and any brokerage package approved? </p><p>Name: ______</p><p>Do you consent to Synapse obtaining information about this application from your preferred supplier or service provider? Please tick as appropriate Yes  No  Section 3: Nature of your support needs </p><p>When did your Brain Injury happen?</p><p>What was the cause of your Brain Injury?</p><p>Have there been any further complications? If so, please describe.</p><p>How does your Brain Injury affect you? Please circle</p><p>Mobility Short term memory loss Organisational skills</p><p>Communication Seizures Anger or frustrations</p><p>Physical (please Chronic Pain Fatigue specify) ______</p><p>Other ______</p><p>Please add any other information about your Brain Injury that you think is relevant</p><p>Have you received compensation for your Brain Injury? Please tick  Lifetime Care and Support  WorkCover  Victims of Crime  Other………………………………………………………………………………………….</p><p>Are you currently doing any formal rehabilitation? Please tick  Yes  No</p><p>If yes, how is this funded? Please tick  Medicare  Health Fund  Self-funded  Compensation  Insurer Section 4: Your plan </p><p>Briefly explain what you hope to achieve with the brokerage program funding?</p><p>What are the barriers to you doing this? Please tick all relevant</p><p> Cost  Transport  Physical access  Need support  Communication  Lack of services  Need professional advice  Need new skills  Other (Please explain)______</p><p>How do you plan to try and overcome these barriers?</p><p>How long do you think this will take?  3 months  6 months  Other……………..</p><p>What difference would this make to you? </p><p>Do you have any documents you wish to attach to support your application? Written by: Date: Written by: Date: Section 5: Financial information </p><p>What is the total amount that you need for this plan?</p><p>What goods or services do you plan to purchase with the funding? Please be clear and concise</p><p>Where else have you sought funds or support for this plan? What happened?</p><p>Please list all sources of income</p><p>Budget-Please provide two quotes for each line of the outlined budget and attach to this application</p><p>Price of each Service/Equipment Quantity Supplier item</p><p>See guidance notes regarding GST Total</p><p>Do you have a preferred supplier? If so, please explain why it is preferred? </p><p>Please certify that you are satisfied that:</p><p>. any equipment obtained with the funding will be covered by a warranty;</p><p>. any modifications proposed will be carried out by a licensed operator; and . the provider of any services has the necessary insurances, and qualifications to deliver the services and meets WHS obligations;</p><p>If the application is successful, who will be sending Synapse a tax invoice or receipt? See guidance notes</p><p>Are there any special circumstances that require an alteration to our usual application process? See guidance notes</p><p>Declaration: I certify to the best of my knowledge that the information provided on this form is correct. If this application is successful the funds will be used only for the purpose outlined on this form. Any alterations to this are to be agreed in writing by Synapse. I accept the following conditions of the program;</p><p>. Synapse grants approval on the basis that you and/or your support network have done the necessary research.</p><p>. Synapse does not take any responsibility for ongoing maintenance, or any harm or damage caused by any equipment or services purchased with these funds. </p><p>. Synapse is required to report to the NSW Department of Family & Community Services - Ageing, Disability and Home Care (ADHC) regarding payments made under the program and I consent to details of my name, year of birth, and Local Government Area being provided for that purpose.</p><p>. Funds must be activated within 3 months of being approved and used within 6 months of approval.</p><p>. I will provide a brief final report to Synapse once the package is completed indicating that the funds have been expended and the outcomes achieved with the package.</p><p>Signature of applicant: ______Date: ______</p><p>Signature of primary contact: ______Date: ______(If other than the applicant.)</p><p>Please send the completed form to: </p><p>Mail: Brokerage Program Synapse PO Box 698, Epping NSW 1710 or Fax: 02 9868 5619 or Email: [email protected]</p>