Caregiver Respite Self Screening 2021
This program is offered with funds from the Arizona Lifespan Respite grant. This is a collaboration of the Arizona Caregiver Coalition with the Department of Economic Security (DES) and the Area Agencies on Aging and their Association (AZ4A). When you submit this form to the Arizona Caregiver Coalition, we will let you know if you meet requirements and are eligible to submit an application.
Family Caregiver Name
Are you interested in the day center respite or the voucher?
Adult day center respite (over age 18)
Respite voucher (caregiver makes own arrangements, can be in-home)
Street Address Line 2
State / Province
Postal / Zip Code
What is your relationship to the person you care for? "I am the ...."
spouse / domestic partner
son / daughter (in law)
sibling (brother, sister, step/adoptive)
Language other than English? (leave blank if not needed)
How did you hear about us?
Media, news, radio
Please answer all these screening questions
You (caregiver) and your family member
Do you and the care recipient live together? (must be YES)
Are caregiving duties causing you stress or health issues?
Does the family member need constant care or supervision? (if no, please explain in "Notes" how much care or supervision is needed))
Do you work outside the home?
Is the person you care for over 18? (must be YES for day center program)
Have you received respite from the Coalition before?
Does the person you care for have any of these services?
Arizona Long Term Care (ALTCS)
Hospice Medicare benefit with respite in a facility
Veteran's Administration (VA) Aid and Attendance
Developmental Disability Services incl. respite
Area Agency on Aging respite (ADHC or in-home)
Other state or federally funded programs related to respite
Do you (the caregiver) help with one or more of these activities regularly?
Personal hygiene, bathing, grooming and oral care
Dressing, making clothing choices and ability to dress's oneself
Eating (feeding the person, not necessarily preparing food)
Maintaining continence (help to use the bathroom)
Transferring (moving from seated to standing or help in/out of bed)
Special care beyond parenting (should be marked "Yes" if the care receiver is under 18)
Leave blank. For office use only.
Should be Empty: