Respite Program Application June 2023

Respite Program Application (2023)
Name of FAMILY CAREGIVER applying for respite*

First NameLast Name
Do you live in Maricopa County?*

YesOther
Are you a veteran or is your family member a veteran?*

YesNo
If yes, were you referred to this program by Duet or the Department of Veterans Affairs (VA)?*

YesNoOther
Are you (the caregiver) participating in any caregiver educational workshops or caregiver support groups? (Required for the Veteran Respite Voucher Program)*

YesNo
If yes, please list the educational workshops and caregiver support groups you are participating in below. In no, please input N/A into the box below.*
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who are you caring for?

Spouse/PartnerBrother or sister/In-LawParent/In-LawAunt/UncleCousinNiece/NephewFriendChild/grandchild (including adoptive/step)Other
How long have you been providing care?

Less than 1 year1-2 years3-5 years6-10 years11 or more years
Please select your gross annual income.
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 (short term up to $1200, must document need)Adult Day Center RespiteVeteran Respite Voucher Program - referral from Duet of VA (Proof of Veteran Status and participation in Caregiver Support Group required)Other, for example, training, help find resourcesNot sure yetOther
NOTE: A referral from the VA or Duet, proof of Veteran status and participation in educational workshops or caregiver support groups is required for enrollment into the Veteran Respite Voucher Program.

Educational Workshops or Caregiver Support Group Acceptable Documents

i. Class roster signed by instructor with organization name and dates caregiver attended class.

ii. Email proof of enrollment in class or support group with organization logo, title or class/group, dates, and times of group.

iii. Attendance sheet provided by ACC with caregiver information, organization information, class title, and the dates and times of caregiver's attendance with the instuctor's name and signature.

Flyers of the class/workshop/support group provided in addition to documents above are preferred.
Other program options in Maricopa County. 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 (2023)

Tell us about the person you are caring for (the care receiver)

Tell us a little more about your family member:

Tell us about yourself, the caregiver

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