Lifespan Respite Program Application 2025

Lifespan Respite Programs application

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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 its entirety, including Caregiver Assessment Tool (CAT) and exit interview.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.

MaleFemaleNon-BinaryPrefer not to say

YesNoPrefer not to say

yesnoPrefer not to say

	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

Respite Voucher $599 per yearRespite Voucher $1200 per year with IRS form W9Respite Voucher $2400 per year with IRS Form W9 (additional documents required)Emergency Respite (Must document need)COPE Program - Oakwood Creative CareNot sure yetOther

Funding for a social worker or care navigatorFunding for respite activities, leisure time activitiesFunding for classes or trainingReimbursement for home modification or assistive technology

Street Address

Street Address Line 2

CityState

Zip Code

	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

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

MaleFemaleNon-binaryPrefer not to say

yesnoPrefer not to say

	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 respite 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 worsened 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?

Arizona Caregiver Coalition and the Arizona Department of Economic Security, Division of Aging and Adult Services, will not be held responsible for any actions taken by the agency/provider I choose.Completion of this Respite Program application does not guarantee that I will be eligible for the Respite Program.Caregiver agrees to complete application in it's entirety, including Caregiver Assessment Tool (CAT) and exit interview.

How to Submit Documentation

Attach/upload below
Email: info@azcaregiver.org
Mail: Arizona Caregiver Coalition, PO Box 21623, Phoenix, AZ 85036

Please use the space below to attach/upload required documentation:

A copy of Caregiver’s Government ID/Driver's License
A copy of Care Receiver’s Government ID/Driver's License - If your family member is under the age of 18, a birth certificate or certificate of guardianship is acceptable.
A completed Medical Needs Form signed by your Care Receiver's physician, if applying for the $1,200 Respite Voucher. This can be found on our website here: https://azcaregiver.org/wp-content/uploads/Respite-Programs-Medical-Needs-Form-1.pdf
A completed W9 form, if applying for the $1,200 Respite Voucher. The form is available here: https://www.irs.gov/pub/irs-pdf/fw9.pdf
Documentation of financial hardship (Example: ALTCS denial letter, public benefit award (TANF, WIC SNAP, etc.)

We've moved our application!

Respite Program Application (2025)

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.