Respite Voucher Program Application Form

Respite Voucher Program Application Form

Aviv Older Adult Services of JF&CS
Thank you for your interest in the Caregiver Respite Program. Please carefully review the eligibility criteria for the program below. Please note we cannot provide respite funding for a loved one (care recipient) that is currently enrolled in a Medicaid waiver program (Elderly & Disabled Waiver Programs: CCSP or Source).

Unfortunately, these eligibility guidelines are firm, and we are not able to make exceptions. If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866. AGEWELL (1.866.243.9355)
Eligibility Guidelines:

1) Are you a family caregiver or other informal caregiver providing care to a loved one (care recipient) under one of the following circumstances?
- Adult family members or other informal caregivers age 18 and older providing care to individuals 60 years of age and older
- Adult family members or other informal caregivers age 18 and older providing care to individuals of any age with Alzheimer’s disease and related disorders
- Older relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities
I acknowledge that I am a family caregiver or other informal caregiver providing care to a loved one (care recipient) under one of the above circumstances. *

Yes No
2) Do you (the caregiver) reside in the 10-County Metro Atlanta Region (Dekalb, Fulton, Gwinnett, Cobb, Clayton, Henry, Rockdale, Cherokee, Douglas, Fayette)?
I acknowledge that I reside in one the above listed 10 counties. *

Yes No
3) Does your loved one (care recipient) currently reside outside of the following settings: personal care home, assisted living community, memory care community, continuum of care retirement community (CCRC), short-term rehab, skilled nursing facility/nursing home?
I acknowledge that my care recipient meets the criteria listed above. *

Yes No
If you answer Yes to all three questions above, then you are eligible to apply for the Respite Voucher Program. Please complete the application.

If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866.AGEWELL (1.866.243.9355).

Respite Voucher Program Application Form
Name of Primary Family Caregiver *
(the person applying for respite voucher funds)
Name of Respite Care Recipient *
(the person receiving respite services)
Street Address for Primary Family Caregiver *
City for Primary Family Caregiver *
State for Primary Family Caregiver *
Zip Code for Primary Family Caregiver *
Primary Phone Number *
Please enter a valid phone number.
Email *
example@example.com
1. Under what circumstances are you as the primary family caregiver providing care to a loved one (care recipient)? *

Adult family member or other informal caregiver age 18 and providing care to individuals 60 years of age and older Adult family member or other informal caregiver age 18 or older providing care to individuals of any age with Alzheimer's disease and related disorders Older relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities
2. What is your relationship to the respite care recipient? *

Adult Child Spouse Sibling Other
3. Why are you requesting assistance through the Respite Voucher Program? *

A break from caregiving to attend to my needs (i.e., go on vacation, date night, go to the store) Increased support following hospitalization or rehab Bridge increased level of care prior to move to assisted living, skilled nursing or other facility Other
4. In which county in the 10-County Metro Atlanta region do you as the primary family caregiver reside? *

DeKalb Fulton Gwinnett Cobb Clayton Henry Rockdale Cherokee Douglas Fayette
5. Please provide the name and address for your loved one (respite care recipient)? *
6. With what tasks or activities do you need assistance for your respite care recipient? (Mark all that apply) *

Bathing Companionship Dressing Transferring/Mobility Toileting Eating Companionship Transportation Meal Preparation Cleaning/Laundry Shopping Adult Day/Adult Day Health Program
7. Do you live in the same residence as the respite care recipient? *

Yes No
8. Are you currently using respite services (home care or adult day)? *

Yes No
9. If yes, will the Respite Voucher be used for a service you are already receiving?

Yes No
10. Do you currently pay for these respite services?

Yes No
11. Date(s) and hours (estimated) you plan to use respite services:
12. Do you have a provider of respite services identified that you plan to use? *

Yes No
If yes, what is the name of the provider?
13. How did you hear about the Respite Voucher Program? *

Atlanta Regional Commission Jewish Family & Career Services Website AgeWell Atlanta I&R Concierge Flyer or other advertisement Family/Friend Other
Primary Family Caregiver Information
Date of Birth of Primary Family Caregiver *

Month Day Year
Date
Age of Primary Family Caregiver *

18-25 26-36 37-46 47-59 60+
Gender of Primary Family Caregiver *

Male Female Other
Marital Status of Primary Family Caregiver *

Single Married Divorced Widowed Domestic Partner
Total number of ADULT family members in Family Caregiver's household: *
Total number of CHILDREN (under 18 years) in Family Caregiver's household: *
Race/Ethnicity of Primary Family Caregiver *

African American Asian Caucasian Hispanic/Latino Multiracial Native American Pacific Islander Other
Respite Care Recipient Information
Name of Respite Care Recipient (the person receiving respite services) *
Date of Birth of Recipient: *

Month Day Year
Date
Age of Recipient *

18-25 26-36 37-46 47-59 60+
Gender of Recipient *

Male Female Other
Marital Status of Recipient *

Single Married Divorced Widowed Domestic Partner
Race/Ethnicity of Recipient *

African American Asian Caucasian Hispanic/Latino Multiracial Native American Pacific Islander Other
Using the list below, please write the disability or special need in the appropriate location (if other, please specify)

Intellectual/Developmental Disability: Intellectual Disability, Autism

Physical/Orthopedic/Mobility Impairment: Multiple Sclerosis, Muscular Dystrophy, Cerebral Palsy

Sensory/Communication Impairment: Blind/vision impaired, Deaf/hard of hearing

Mental/Emotional/Psychosocial Impairment: Mental Illness, Mood/Personality Disorders

Degenerative Neurological Impairment: Dementia/Alzheimer’s, Parkinson’s, ALS

Neurological Impairment (nondegenerative): Stroke, Traumatic Brain Injury, Spinal Cord Injury

Medically Fragile/Frail Elderly

Other (please specify below)
Primary Disability or Special Need: *
Secondary Disability or Special Need (optional):
Other: (please specify)
Acknowledgements

Primary Family Caregiver: Please read and initial each item below.

Sign and date form before submitting the application
to Aviv Older Adult Services of JF&CS.
I understand that the intention of the Respite Voucher Program at Jewish Family & Career Services (Aviv Older Adult Services) is to allow the primary family caregiver to get a break from providing care for their loved one by providing in home services or adult day care. *
Type your initials
I understand that the service I receive from the Respite Voucher Program of Jewish Family & Career Services (Aviv Older Adult Services) are solely for services provided to the respite care recipient listed on this application and that these funds cannot be used for any other individual. *
Type your initials
I understand my signature below authorizes a release of information for program purposes only.. *
Type your initials
Jewish Family & Career Services administers the Respite Voucher Program to provide short-term funding for respite care services but does not provide these services directly or indirectly. I attest that the information included in this Application Form is true and accurate to the best of my knowledge. I understand that falsification of information will result in termination of services.
Signature of Applicant (Primary Family Caregiver) *

Clear
Date *

Month Day Year
Date
Print Name: Applicant (Primary Family Caregiver) *
Please sign and email this form to caregiver@jfcsatl.org.

If you experience any problems with this application and/or have additional questions, please contact Mandy Rappoport at (470) 433-5957.
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Respite Voucher Program Application Form

Respite Voucher Program Application Form

Primary Family Caregiver Information

Respite Care Recipient Information