Lifespan Respite Program Application Feb. 2024

Respite Program Application (2024)

The Arizona Caregiver Coalition (ACC) administers the Lifespan Respite grant in partnership with the Arizona Department of Economic Security (DES). Funding comes from the Administration for Community Living (ACL).
Please READ CAREFULLY and mark each item after reading:*

Caregivers are defined as an adult family member or individual who: 1. Has a significant relationship with their loved one (CARE RECEIVER); 2. Provides a broad range of assistance to a care receiver with a chronic or other health condition, disability, or functional limitation; and 3. Provides constant care to care receiver that cannot be left alone.Caregivers must reside full-time with the care receiver.Caregivers and care receiver cannot be receiving any other respite services paid with federal, state or insurance funds. The Lifespan respite program is at no cost to caregivers who do not receive respite from other federal or state programs.Caregivers will be responsible for selecting, screening, and arranging care with a provider/agency.Respite providers must be over age 18, cannot live in the same household as the care receiver and offer orientation and training as needed. Respite providers can be trusted family, friend, or neighbor.Caregivers are responsible for any balance due if they exceed the allotted voucher funds.Caregivers must submit a signed IRS W9 form for reimbursement funds more than $599.Caregivers must submit a Medical Needs Form and have it signed by a medical provider before being determined to be eligible for the Respite Program.Caregivers must submit a government issued ID for both the caregiver and care receiver.Caregiver agrees to complete application in it's entirety, including Caregiver Assessment Tool (CAT) and exit interview.
Name of FAMILY CAREGIVER applying for respite*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Your date of birth*

MonthDayYear
Date
Please select your gross annual income.
Your gender*

MaleFemaleNon-BinaryPrefer not to say
Do you work outside the home?

YesNo
What is your level of education?*

Grade School or LessSome High SchoolHigh School GraduatePost High School GraduateCollege DegreePrefer not to say
Are you a veteran or is the care receiver a veteran?*

YesNoPrefer not to say
Do you prefer a language other than English? (leave blank if not needed)*

NoSpanishOther
Race*

AsianBlack/African AmericanNative Hawaiian or Pacific IslanderAmerican Indian or Alaskan NativeWhiteOtherPrefer not to say
Are you of Hispanic/Latino background?*

yesnoPrefer not to say
Tell us more about yourself:
Who are you caring for?*

Spouse/PartnerBrother or sister/In-LawParent/In-LawAunt/UncleCousinNiece/NephewFriendChild/grandchild (including adoptive/step)Other
Have you received respite from the Arizona Caregiver Coalition before? (It's okay to apply again!)*

YesNo
How long have you been providing care?*

Less than 1 year1-2 years3-5 years6-10 years11 or more years
Can you demonstrate a financial hardship. Examples include a denial letter from AZ Long Term Care Services or a public benefit award letter (SNAP, TANF, WIC, etc...).*

YesNo

Do you currently use any RESPITE services?*

	Yes	No
Arizona Long Term Care (ALTCS)
Hospice Medicare benefit with respite in a facility
Veteran's Administration (VA)
Developmental Disability Services
Area Agency on Aging Respite (ADHC or in-home)
Other respite programs , perhaps from your insurance
I pay for respite myself

Have you received respite from the Arizona Caregiver Coalition before? (It's okay to apply again!)

YesNo
Which program are you interested in? Mark all you are interested in.*

Respite Voucher $599 per yearRespite Voucher $1200 per year with IRS form W9Emergency Respite (Must document need)Other, for example, training, help find resourcesNot sure yetOther
Other AZ Lifespan Respite Program options. Mark all you are interested in.

Funding for a social worker or care navigatorFunding for respite activities, leisure time activitiesFunding for classes or trainingReimbursement for home modification or assistive technologyOther
Add any comments or questions you have:

	Yes	No
Personal hygiene, bathing, grooming, and oral care
Dressing, making clothing choices and ability to dress one's self
Eating (feeding the person, not necessarily preparing food)
Maintaining continence (help using the bathroom)
Transferring (moving from seated to standing or help in/out of bed)
Medication Management
For children: Do they need special care beyond regular parenting?
Other

	No, not at all	Yes, somewhat	Sure, Definitely
You have friends and family who can care for your loved one until you get back home
You have organizations or providers (formal support) who can provide repiste and care (even on short notice) while you are away
Your friends, providers or emergency personnel can find the necessary information to maintain your loved one's care? (for example: medications list, insurance, health care provider phone number
Your friend, family or respite provider can understand the daily needs and preferences of your loved one to make sure they get good care

	Yes	No
3.1 - Felt cut off from your family/friends?
3.2 - Felt overwhelmed?
3.3 - Had trouble falling asleep, staying asleep, or waking up too early in the morning?
3.4 - Noticed your eating habits worsten as a result of your caregiving?
3.5 - Been frustrated or angry as a result of your caregiving?
3.6 - Often felt sad or depressed?
3.7 - Often felt nervous or anxious?
3.8 - Had crying spells or often felt like you needed to cry?

Respite Program Application (2024)

Tell us more about yourself:

Tell us about the person you are caring for (CARE RECEIVER)

CAREGIVER ASSESSMENT TOOL This is all about you, the person caring for a loved one.

	Yes	No
Arizona Long Term Care (ALTCS)
Hospice
Veteran's Administration (VA) Aid and Attendance
Developmental Disability Services