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Attachment A: CSN referral and process
In response to FOI request 24/25-1885 (Gemma).
CSN Referral Process
The referral of a NDIS participant to the Complex Support Needs (CSN) branch and
its specialised planning pathways are an internal only process typically completed by
a state-based service delivery delegate.
In the context of the NDIS, complex support needs are defined as a situation where
a person has extraordinary support needs based on the presence of situational and
personal factors that demand a greater need for coordination of multiple services.
When submitting a referral to the CSN pathway for a NDIS participant the delegate
must identify the following situational and personal factors and note them in the CSN
Referral for Assessment Form (
see Attachment B CSN Referral for Assessment
Form).
• Accommodation:
o Risk to homelessness
o Children living outside of the family home or in immanent need for
outside accommodation.
• Disability
o Multiple and complex disability diagnosis
o Multiple family members with a disability
• Engagement with government services
o Voluntary or involuntary involvement in other government service
systems. In particular health, child protection, guardianship orders,
mental health and justice that impact the participants ability to engage
with the NDIS.
• Vulnerability and risk
o increased risk of significant harm from abuse or neglect
o impact of trauma or abuse
o limited or no expressive communication.
• Support and care
o Limited or no informal supports (for example, advocate, guardian,
nominee) and informal support (for example, family member, carer,
friend support) to assist with decision making or engaging in planning.
o Transitional supports for returning to the community (for example
leaving rehabilitation or hospital, incarceration)
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o Stressed care arrangements. An immediate unmet need for targeted
support or a crisis situation due to a sudden unexpected change in the
person’s circumstances.
• Provider Market
o The ability for the provider market capacity to support people
o Limited or no services available in the participants area
o Thin or exhausted markets in regional and remote areas.
The referral form is submitted for assessment through the PACE business system.
PACE is the customer relationship management tool used by the NDIA to manage
the interactions and planning with participants.
CSN Criteria for ECEI participants
The National Early Childhood (NEC) Branch is responsible for delivering quality
outcomes for young children and their families. The NEC is a specialised team that
connects with participants and their families during early childhood (under 9 years of
age) and assist with planning and access to supports.
The CSN branch has a children and young people pathway, referral to this pathway
is the same process and criteria as all other NDIS participants.
CYP criteria response and guidelines.
The Children and Young People Team provide specialised support to NDIS
participants within Complex Support Needs pathway. The team works collaboratively
to provide a 'wrap-around' service for the child or young person, and their family. We
focus on an early intervention and prevention approach that supports children and
young people to access the disability supports they need during key life stages and
transition points.
The CYP approach helps to build the capacity of each child or young person to, for
example, maintain and improve their connection to their family, keep them within or
support their return to the family home, or develop their independence to live in the
community as they transition to adulthood.
The Children and Young People Team works closely with other Complex Support
Needs Branch teams, State and Territory Government colleagues and providers to
ensure a holistic and goal focussed service that meets the needs of the children and
families they support.
• Children and young people who might benefit from support by this team may
have personal and situational considerations such as:
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Severe and complex neurodevelopmental disability, physical impairment and/
or significant functional impacts of disability across all domains
• Complex and challenging behaviours that place themselves, others, or
property at risk of harm and/or damage
• Disability-related health care needs requiring high levels of one-on-one care
including delegated nursing tasks
• A range of complex mainstream interface considerations or gaps that can be
supported alongside our state and territory partners; including for example
Education, Child Protection, Health and Mental Health and Housing needs
• Family characteristics such as requiring support to sustain parental care and
responsibility due to the complex nature of their child's disability
circumstances.
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s47E(d) - certain operations of agencies
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s47E(d) - certain operations of agencies
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This means the state or territory child protection service (child protection) now has parental
responsibility for the child and not the parent (or primary care giver). There are two types of
OoHC. These include home-based and residential-based OoHC.
When we say statutory home-based OoHC, this is where:
•
a state or territory government determines a child can't live in their family home
•
the child now lives in foster care. A foster carer is trained and approved to care for children
•
the child now lives in a kinship carer's home. Kinship carers are relatives or family friends of
the child
•
the state or territory government pays for the expenses of caring for the child.
•
the NDIS funds disability support needs for the participant including capacity building and
some core supports.
When we say statutory residential-based OoHC, this is where:
•
the child now lives in residential-based care. Residential-based OoHC includes group homes,
private rental homes, large residential care settings and temporary care settings such as a
motel
•
the state or territory government pays for the accommodation and support workers who are
responsible for their day-to-day care
•
The NDIS funds disability support needs for the participant such as capacity building,
behaviour support, therapeutic supports.
What isn't statutory out-of-home care?
Children living in the family home, with involvement from child protection
Sometimes a court decides a child needs protection but they can safely stay in the care of their
parents. Parental responsibility for the child remains with the parent. Child protection stay
involved to help the family. This is to make the changes they need to keep the child safe at
home.
In these situations, court orders will include conditions that require child protection to be advised
of and involved in any issues related to the child, including:
•
medical
•
schooling
•
NDIS planning.
In these situations, you'll follow the usual NDIS planning process. Child protection staff will stay
involved in all matters relating to the child. Child protection are responsible for the child and their
family's mainstream supports in these situations. This may include:
•
funding any psychological support to a child following trauma or abuse
•
family or parental counselling related to child protection matters.
Planning considerations for children living in statutory out-of-home care
Statutory OoHC orders can be managed by the relevant state or territory government or by a
non-government agency contracted by the state or territory government.
You must:
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obtain a copy of the legal order. To learn more about adding evidence to a person account,
go to article Add and link evidence to a case
•
understand the legal order and the length of time it applies for. For example, the order may
be for a temporary period or until the child turns 18.
You must confirm with the child protection case worker or team:
•
who the lead agency is
•
who the legal guardian or child representative is
•
who needs to be involved in the plan meeting or given the opportunity to contribute.
Some examples of who might need to be involved in the planning meeting includes:
•
the participant
•
state or territory child protection representative or non-government agency
•
foster carers or kinship carers
•
guardian, parents or other family members
•
providers.
How to prepare for a plan meeting
Before the participant's plan meeting, to help develop the plan you should talk with their case
worker. To learn how to view the case worker's details, go to article Check consent, nominee,
child representative or self-representation authorities.
Talk with the case worker about valuable contributions current carers can make to the
participant's plan. This may include foster or kinship carers, other family members and residential
care providers and staff. They can provide information about the day-to-day life of the child or
young person, their likes and interests and information on their disability support needs. If this
isn't possible, you should encourage the case worker to gather all relevant information from the
participant's current carers. Ask them to submit the information before or bring it to the plan
meeting.
Case workers may also give us reports from allied health professionals. To learn more about
adding evidence to a person account, go to article Add and link evidence to a case.
In these situations, it's important you don't share personal information, such as home address, on
the participant's plan or in other correspondence. It may be appropriate to record the address of
the child protection agency as the child's home address in PACE. To learn more, go to article
Record an address for a child.
Review the reasonable and necessary disability-related supports in the child's plan. To learn
more, go to Our Guideline – Reasonable and necessary supports (external). If you need help to
determine these supports for a child living in statutory OoHC, talk with your relevant subject
matter expert.
If you need advice based on a particular participant situation, you can ask for help from the
Children and Young People Team.
You can use the Plan conversation support tool to help you record reasonable and necessary
decision making. You
must use the PCST for all new plans and plan reassessments and attach
to the participant record. To learn more, go to article Understand and update the plan
conversation support tool.
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Core supports
Core supports for a child in statutory OoHC include:
Respite for children and young people living in home-based OoHC
Respite means carers can take a short break from their caring roles. It can help to:
•
provide stable child protection placements
•
complement mainstream and NDIS-funded supports.
There are 2 types of respite for children in statutory home-based OoHC:
•
ordinary respite
•
additional respite.
Ordinary respite
Child protection provide short breaks or respite for carers of children with or without a disability
who are in statutory OoHC.
Additional respite
We may also fund short breaks or respite for children with disability in statutory home-based
OoHC.
Additional respite would not be provided for participants in residential-based OoHC as carers in
these settings are funded by the state or territory government. To learn more, go to Child
protection and family support (external) and Our Guideline – Short Term Accommodation or
Respite (external).
Support for children living in residential-based OoHC
No child should be at a disadvantage because they are in a residential-based care setting. They
are eligible for the same disability-related supports as any other child.
It's the responsibility of the state or territory government to provide accommodation and staffing
for children living in residential-based OoHC.
We may fund reasonable and necessary disability-related supports for children living in
residential-based OoHC. This could be to support their access to the community, or with social
participation. It can also help build or maintain their support networks.
For example, a child participant in residential-based OoHC who needs 2:1 supports. We may
consider it reasonable and necessary to fund the second worker to support the participant's
disability support needs. This is in addition to the support worker funded by the state or territory
government.
Note: When significant supports are needed for a participant in statutory OoHC, advice from your
manager (including Technical Advice and Practice Improvement Branch when relevant) is
required.
Children with complex support needs
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agency-managed
•
managed by a registered plan manager.
Alternatively, child protection, as the legal guardian, can request in writing to appoint the foster
carer as the plan nominee. This means the foster carer would manage NDIS-funded supports in
the child's plan. To learn more, go to Our Guideline – Child representatives (external).
Capital supports
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therapy and behaviour supports. For example, supports to help the child develop skills to
build independence in the home, community, place of education or work
•
in-home support for carers. For example, a disability support worker to care for the child in
the carer's home for short periods. This gives the regular carer a break. Or gives extra care in
the home while the carer remains at home
•
community-based daytime respite. For example, the child receives support to go to
community activities at a camp, park, museum or participate in group activities
•
equipment and transport supports
•
social and recreation support is not usually funded but may meet the NDIS funding criteria.
For example, extra help for a child with a disability to participate in social and recreation
activities, without the regular carer being there. This includes visiting a friend or family or
playing a sport. For more information, go to Do we expect your family, friends or the
community to provide the social and recreation support? (external).
Transition to adulthood planning
Transition planning is the process of assessment, planning, implementation, and review to
identify the needs of a young person as they move into adulthood.
As a young person prepares to transition out of statutory OoHC they may require additional
support to:
•
move out of their statutory living arrangement into an alternative living arrangement
•
build or maintain family or social support networks
•
leave school and start work or join community activities
•
transition to the disability support pension (DSP).
For more information, go to the Children and Young People (CYP) intranet page.
Case example: Michael
Michael is 9 years old and lives with his foster family and 2 siblings. He is in a statutory out-of-
home care arrangement that will be in place until he is 18 years of age. He doesn't have any
contact with his biological parents. Michael's primary disability is autism spectrum disorder.
Michael attends school 5 days per week. He receives funded education support to engage in his
learning for most of his school day. This support isn't funded by us. The school have a
behavioural management plan in place to help staff respond to Michael as the need arises.
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a therapist who will continue to oversee Michael's behaviour support plan including training
for foster parents and other supports in the behaviour support strategy
•
capacity building supports to help Michael continue to build his independence such as
occupational therapy supports to help Michael build his capacity with personal hygiene and
dressing
•
coordination of supports 3 hours per month (36 hours per year) to support Michael's foster
family to implement his plan and to connect and coordinate services and supports
•
short term accommodation (respite). This is to help Michael's carers sustain their caring role.
It is considered reasonable and necessary to fund 14 days within a 12-month period
•
social and community participation supports 3 hours per week on the weekend. This means
Michael can take part in community activities and provides a respite effect to his carers so
they can meet the needs of their other children.
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•
Participant safeguarding policy (external)
•
Article Support categories
•
article Understand support coordination and psychosocial recovery coach funding
•
article Guide – Behaviour Support.
Reasons a family may be in crisis due to their child or young person's disability support needs
The family of a child or young person with significant disability-related support needs may
identify that they're having difficulty managing behaviours in the family home. Some of these
might include:
•
child characteristics, like escalating complex and chal enging behaviours including abuse,
property damage and violence
•
non-attendance at school
•
indicators, like parents who have limited access to appropriate services because they live in a
remote location.
There can also be situations where the functional impact of the child or young person's disability
means the family need higher levels of support to sustain care in the family home.
The best place for a child or young person is in the family home. Family can mean different things
to different people, but it's essential for a child to live with their loved ones wherever possible.
Early intervention is important because putting the right supports in place early can help
maintain the family living together. These might include in-home supports, support coordination,
capacity building, behaviour support and disability support worker training. This can help to
implement consistent behaviour management strategies in the home environment.
Children have many milestones and transitions in their lives that you need to consider when you
build their plan. Making sure the supports are sustainable in the future is crucial for their
development.
We generally don't fund supported independent living (SIL) or specialist disability
accommodation (SDA) for children or young people. Unless a child or young person is in a
statutory arrangement, they are provided with supports and accommodation by their parents or
guardians.
If there are parental capacity or mainstream interface issues, mainstream services should be
provided through the relevant child safety agency. For example, if:
•
a parent or parents are unwell or deceased
•
housing is inappropriate
•
there is a substantial risk to the child.
The NDIA wouldn't general y fund this. To learn more, go to Mainstream and community
supports - Child protection and family support (external).
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want more out-of-home supports
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want more short-term accommodation (STA)
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experience disability themselves
•
run out of funding early
•
experience behaviours of concern. This might look like property damage or abuse by their
child
•
experience a loss of respite effect if the child only attends school intermittently or not at all.
There may also be:
•
siblings impacted by the child's disability
•
multiple people in the household who are NDIS participants
•
other issues in the home such as domestic and family violence, drug and alcohol abuse or
mental health concerns. Or the family might be isolated, in a rural or regional area or a single
parent family.
Generally, mainstream services are the appropriate response to homelessness. Funded supports
need to meet the NDIS funding criteria (external).
In some rare instances, young people who are nearly 18 years of age can request an exceptional
circumstances approval for SIL or SDA if they are eligible, particularly if the behaviours of concern
are significant. This isn't a response to homelessness and you must prioritise evidence-based
decision-making.
Planner considerations
When you consider supports in the participant's plan, think about:
•
whether the child has good supports in place, such as in-home supports, capacity building
including a behaviour support plan, support coordination or STA. If there aren't good
supports in place, a plan reassessment is needed. This wil make sure relevant disability-
related supports are included to help keep the child in the family home.
•
if good supports are in place, whether they meet the NDIS funding criteria
•
if the child protection agency requests STA whilst they are undertaking an assessment, this
isn't something the NDIA would normal y fund.
Generally, it isn't appropriate for a family to request an urgent plan reassessment if they have
over utilised funded supports in the child participant's plan. This could be an NDIS integrity issue
which may involve fraud and potentially a child protection response.
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Overutilisation can raise questions like:
•
Who is caring for the child?
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Who is the decision-maker?
•
Which safeguarding and compliance measures are in place?
•
Is a registered provider being used for restricted regulated practice (RRP)?
•
Is STA being utilised?
•
Is funding during school hours being claimed?
Other risks you need to think about if the child is being supported out of the family home:
•
Does the provider understand the risks they are taking by supporting a child 24/7 out of
home?
•
Is the Provider Engagement Team engaged?
•
Has a fraud report been submitted? To learn how, go to the Fraud Investigations Branch
intranet page.
•
Have child protection reports been submitted by the support coordinator or provider
because the child isn't being supported by a parent or guardian?
•
How often does the parent see the child?
•
Who is monitoring the supports being provided?
•
Have any participant critical incidents been identified and reported? Go to article Understand
participant critical incidents to learn more.
•
Who is monitoring and safeguarding the child?
•
How are routines being maintained? For example, school attendance or behaviour support
plan strategies implemented.
Community and mainstream supports
Participants have access to the same community and mainstream supports as any other child or
young person. Families and participants may need help to understand what other service systems
can support them, as well as their NDIS funded supports. To learn more, go to Mainstream and
community supports - Who is responsible for the supports you need? (external).
You could also give families information about contacts in their state or territory. To learn more,
go to article Community and mainstream supports contact list.
How to prepare for the plan meeting
The Plan Conversation Support Tool (PCST) can help you record reasonable and necessary
decision-making. You
must use the PCST for all new plans and plan reassessments and attach to
the participant record. To learn more, go to article Understand and update the plan conversation
support tool.
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If you need advice based on a particular participant's situation, you can ask for help from the
Children and Young People Team.
Think about the way you engage with families. Always be supportive, positive and encouraging
when talking with families and participants by listening and acknowledging their concerns. For
more information, go to Guide - Conversation style guide.
Treat families with respect and understand that their circumstances may be very difficult, and
don't act in a judgemental or transactional way.
•
Capacity Building should always be the primary focus. This includes building the capacity of
parents, teachers, support workers and the child or young person.
•
Parent and carer training is essential to build capacity for parents to understand and support
the disability-related needs of their child in the family home.
•
Support Coordination and Specialist Support Coordination is vital. There may be numerous
stakeholders and supports required which can be overwhelming for the family. This can add
pressure, increasing risk of carer burnout.
Core supports
Core support funding in the child's plan can include:
•
assistance with daily life
•
assistance with social and community participation
•
access to social and community activities, like transport.
Talk with the family about how in-home supports can help, for example to help the child get
ready for school. School attendance provides a respite effect and can be important to help a
family or carer continue to care for their child. You can also help link the family with after-school
activities in the community to give the family and siblings a break.
If the young person is 16 years or older and has independent skills, you can fund daily living
supports to help them to live more independently. For example, to support them with self-care,
personal care and meal preparation. This wil be assistance with daily life supports provided in the
family home, not 24/7 core funding supports. You can't fund SDA for this scenario.
Social and community participation
Consider the age of the child and if they need support to join in social and community activities
without their family at times. This can give the family or carer a break if they normal y need to
provide a lot more care than other parents with children of a similar age. A support worker can
be funded so the child can enjoy age-appropriate activities outside their family home, with their
peers. This helps the child to build independence while increasing the child's social participation.
For more information, go to Do we expect your family, friends or the community to provide the
social and recreation support? (external).
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Maintaining current family support
Parents make a valuable, ongoing contribution to the lives and wellbeing of their children. They
support their child to pursue their goals. You must:
•
respect the rights and dignity of parents
•
promote their inclusion in the planning process
•
facilitate access to supports to promote family engagement and capacity building.
Short term accommodation, including respite
Short term accommodation (STA) including respite is funding for a 24-hour period. Whilst this
isn't the main solution, it can provide a break for families and carers. STA, including respite, can
be included for up to 28 days a year in the participant's plan if families and carers need additional
support to help them with their caregiving responsibilities. For more information, go to Do we
expect family and informal supports to provide care for you? (external).
Specialist children's use case
The specialist children's use case is where additional STA, combined with capacity building or
other supports, is considered because the child is at risk of entering residential care.
When considering if additional STA meets the NDIS funding criteria, look at including other NDIS
support options that could help sustain informal care arrangements. For example, in-home
support, behavioural therapies and community access.
For specialist children's use, you can include up to 30 days at a time, not exceeding 60 days per
year. To learn more, go to Our Guideline – Short Term Accommodation or Respite (external).
Capacity building supports
Consider the NDIS funding criteria when including disability-related capacity building supports in
the child's plan. To learn more, go to Our Guideline – Reasonable and necessary supports
(external).
Capacity building supports help increase the sustainability of the family or carer to continue to
care for the child and should be funded alongside any respite. This might include:
•
in-home support
•
training to help implement a behaviour support plan. For example, supporting the child to
develop a sleep routine
•
positive behaviour support strategies to address complex and chal enging behaviours for
parents and other stakeholders
•
support for community access to allow the child and family to increase social participation
and reduce social isolation.
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manage chal enges in their own support environment
•
make sure there is consistent delivery of service.
This support is time-limited, fixed term and targeted to specific identified areas. This should be
clearly communicated if there is an expectation of funding.
It focuses on specific outcomes, such as:
•
identifying housing solutions to support a young person transition to adulthood. This
includes planning for the transition to independent living (if that's the child's goal)
•
identifying strategies and solutions for managing risks, such as re-engaging with school. This
includes coordinating family, education and stakeholders to develop and implement
programs and practices to build relationships linking the child to learning and education. Or
training for parents and stakeholders in behaviour support strategies
•
identifying and sourcing relevant assessment and associated service design for participants
with risk behaviours and behaviours of concern. This includes restrictive practice reporting to
the NDIS Quality and Safeguards Commission (external)
•
participation in any case conferencing arranged by state and territory services if there's a
need to coordinate the participant's disability-related supports with mainstream services
•
engaging with mainstream services
•
helping family or parents to access advocacy supports
•
capturing and presentation of required data for the NDIA (for example from school).
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there is a risk to self or others
•
1:1 (or higher) funded supports are being used for more than 30% of the day
•
if unregulated, restrictive practices are being used.
Behaviour support is vital if there are behaviours of concern. These behaviours might impact the
family dynamic to a point that the child is at risk of needing accommodation outside the family
home.
You should include strategies to support behaviour and build capacity within the family. This
should encourage family engagement for children with high support needs.
In some cases, the behaviours of concern are significant. They could result in the child not being
able to spend time with family without high levels of support. Consider if behavioural supports
can be included so the child can remain living safely in the family home.
These supports should:
•
support the child's safety and wellbeing
•
promote options for increasing the child's capacity, community and mainstream connections
to achieve plan goals
•
help the long-term sustainability of the child's plan and informal support systems
•
reduce or eliminate any restrictive practices that might be in place to improve the child's
quality of life. To learn more, go to Core, Capacity Building and Mainstream Interface
Supports.
As the child's capacity increases over time, you would expect to see a reduction in the intensity
and level of 1:1 (or higher, for example 2:1) supports (greater than 30%). However, this wil
depend on individual circumstances.
Consider if including behaviour support alongside other supports, such as STA for a temporary
period, meets the NDIS funding criteria. This could al ow a family or carer to continue to provide
care for the child. Concurrent supports may be a successful early intervention strategy for highly
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must be registered with the NDIS Commission
•
must meet the supplementary requirements of the NDIS Practice Standards.
Any use of restrictive practice must comply with the NDIS (Restrictive Practices and Behaviour
Support) Rules 2018 (external).
Where there are behaviours of concern and restrictive practice, the child's behaviour support
specialist and providers of core supports must be NDIS registered. Making parts of the child's
plan Agency-managed is one way of guaranteeing a provider is registered. To learn more, go to
article Make fund management decision.
Building family relationships and capacity
Consider if including disability-related capacity building and training for the child's parents could
support their child to engage with the family. These supports are important to help the family
keep caring for their child in the family environment.
Capacity building supports can be included in the plan, so the child remains living in the family
home:
•
Behaviour support may already be in the plan. It should include development or review of a
behaviour support plan, behavioural supports (for example support to establish positive sleep
routines) as well as training for family members.
•
Assessment, recommendation, therapy or training (including assistive technology). For
example, occupational therapy assessment and training to identify equipment, and to train
the participant and their family to use the equipment in the family home.
•
Community access by providing personal care (including supervision of behaviours of
concern) to support the participant to access the community.
•
In-home support: where personal care support needs (including for supervision of behaviours
of concern) are above the needs of other children of similar age.
Capital supports
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Use the information below to guide you through additional considerations for capital supports
when the child is living outside the family home.
Home modifications
Consider any home modifications that could help the child remain in their long-term family
home. To learn more, go to article Add minor home modification funding.
Transition to adulthood planning
Transition planning is the process of assessment, planning, implementation, and review to
identify a young person's needs as they move into adulthood.
As a young person prepares to leave school and start work or join community activities, they may
require additional supports to:
•
transition to the disability support pension (DSP)
•
transition to independent living.
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