Respite care for children with higher needs

Quarterly Respite Provider Report for Caseworkers

Child's Name

Provider's Name:

Reporting period:

From: required

To: required

Date Completed: required

Instructions: Please provide clear, concise, and objective observations based on your time providing respite care for the child during this quarter. If a question does not apply or you lack sufficient information, please note “N/A” or “Not observed.”

Medical Observations:

Has the child been consistent with prescribed medications during respite sessions? If not, please describe:

Have you observed any changes in behavior with any new medication prescribed If yes, please describe.

Physical Health Observations:

Have you noticed any changes in the child’s physical health (e.g., mobility, appetite, energy levels, or physical symptoms)?

Were any medical concerns reported or observed? If yes, please provide details and note if guardians/caseworkers were informed.

Mental Health and Emotional Well-Being:

How would you describe the child’s overall mood and emotional state during respite sessions?

Have you observed any significant changes in the child’s mental health or emotional regulation (e.g., increased anxiety, sadness, or positive changes)?

Sleep Patterns:

Have you observed the child’s sleep patterns during respite care (if applicable)? If yes, describe any consistency or concerns (e.g., difficulty falling asleep, frequent waking, or restful sleep).

Concerning Behaviors:

Have you observed any behaviors that were concerning or challenging during respite sessions? If yes, please describe the behavior, frequency, and how it was managed.

Were these behaviors reported to guardians or caseworkers? If so, when and how?

Strengths and Positive Observations:

What strengths or positive behaviors has the child demonstrated during respite sessions (e.g., social skills, hobbies, resilience)?

Have there been any notable achievements or progress in the child’s skills or abilities?

Communication with Guardians:

Have there been any challenges or successes in coordinating with guardians? If yes, please describe.

Cancellations or Scheduling Issues:

Were any respite sessions canceled or rescheduled during this quarter? If yes, please note the reason(s) and whether guardians/caseworkers were notified.

Additional Information for Caseworkers:

Is there anything else the caseworker should know about the child’s experience during respite care (e.g., preferences, activities enjoyed, or other observations)?

Are there any recommendations for improving the child’s respite experience?

Provider's Signature

Date: required

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