For Referral Sources

Thank you for connecting a family with us! We look forward to working together to arrange respite services for them. To make the referral process as straightforward as possible, we encourage you to reach out with any questions you may have. Below, you'll find the "Respite Services Referral Form" to complete, ideally with the parents. There is a link to upload a completed "Release of Information Form" from your agency, or you can ask the parents to complete one that is on the "For Parents" tab. Once we receive these forms, we will contact the parents to discuss the next steps.

Respite Services Referral Form

Child Information:

Name:

Date of Birth:

Month

Day

Year

Address(es):

County:

Age:

Sex:

Parent(s) Information:

Name(s):

Phone(s):

Email(s):

Family Dynamics:

Legal Guardian's Contact Information:

Lives with:

Other information about the family:

Medical Needs:

Known Triggers:

Allergic Reactions:

Special Needs:

Diagnosis (if known):

Medications (if applicable):

Behavioral Information: If "yes" please elaborate. If "no" write "N/A."

Destroys Property:

Foul Language:

Aggressive Toward Animals:

Aggressive Toward Things:

Aggressive Toward People:

Fire-Starter:

Incontinent:

Suicidal Ideation (SI):

Homicidal Ideation (HI):

Additional Information:

Technology Use: We prefer technology use should be used at a minimum. If and when possible, our preference is for tablet/cell phones to be left at home. Unless it is used for educational purposes. Parents will explain in their intake form.

Referring Party's Contact Information:

Name:

Phone Number:

Email Address:

Agency/Organization:

By typing my name below, I agree that this electronic signature is valid and binding. I confirm that the information provided is accurate and up-to-date.

Organization Representative Signature:

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Date:

Note: Please attach a release of information form.