Form SSMH 5
Application for Supplementary
Funding To Support Students
with Mental Health Difficulties
Students who have more serious mental health difficulties may require resources in addition to what the school can provide, to
enable reasonable educational adjustments to assist the student access curriculum, achieve curriculum outcomes and participate in
school life. Typically, only a small number of students have a serious mental health difficulty that warrants a level of educational
adjustment beyond what schools can provide from existing resource allocations. These students often have a range of difficulties
that are extremely intensive to manage, where significant risk assessment and risk management is involved, and where there is
thorough demonstration that the school has explored all local resources and has consulted a clinical care provider.
Student’s last name:
Date of birth:
Student’s first name:
Chronological age:
EQ ID number:
Gender:
School:
School Year level:
Personnel involved:
School: e.g. parent/carers, case manager, guidance officer, class teacher/s,
 Name / Parent/caregiver
 Name / Role
 Name / Role
 Name / Role
 Name/Clinical Care Provider
Region: e.g. PAES, SGO
 Name / Role
 Name / Role
Interagency: e.g. CYMHS, DCCSDS
 Name / Role
 Name / Role
Supporting documentary evidence to be provided: (May include the following)
Student Plan
Attached:
Risk Management Plan
Attached:
Individual assessments e.g. Functional Behaviour Assessment (FBA)
Attached:
Indicate additional resources this student receives
Area
Evolve, RAI, etc
National Disability Insurance Scheme
Refugee
Multicultural (e.g. settlement support)
Indigenous
Education Support Funding
Over allocation / District resources
Within school resources
Specialised Teacher-aide hours
Yes / No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
No
No
No
No
Amount / Time
Amount / Time
Amount / Time
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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Form SSMH 5
Application for Supplementary
Funding To Support Students
with Mental Health Difficulties
Other relevant information
Principal:
Date:
This completed form should be forwarded to the Principal HR Consultant in your Regional Office.
Regional Office HR personnel will advise the school of the outcome of the application.
The student’s personal information included on this form has been collected, used and distributed for the purpose of
ascertaining and establishing referral and support options for the student’s suspected mental health difficulty, with the informed
consent of the student/parent/carer, pursuant to s.426(3)(b) of the Education (General Provisions) Act 2006 (Qld).
Uncontrolled copy. Refer to the Department of Education and Training Policy and Procedure Register at
http://ppr.det.qld.gov.au to ensure you have the most current version of this document.
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