ADHC Program Application 2024

ACC Adult Day Health Center Program Application 2024

This yearly program allots temporary assistance of up to 96 hours with a qualifying Arizona ADHC of your choosing, paid for by ACC on your behalf! The ADHC program is funded by the Arizona Lifespan Respite grant and is a collaborative effort between the Arizona Caregiver Coalition, the Department of Economic Security (DES), and the Area Agencies on Aging. Upon submitting this form to the Arizona Caregiver Coalition, we will inform you if you meet the requirements and if you are eligible to apply. Please complete this form in its entirety.
[Office Use Only] Application Status

Needs Follow-UpDocuments PendingIn ReviewCompleted
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 Adult Day Health Center 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 an Adult Day Health Center/licensed caregiver. Licensed respite providers must be over age 18; cannot live in the same household as the care receiver; and cannot be a legal guardian, POA, or have a fiscal responsibility for either the caregiver or care recipient.Caregivers are responsible for any balance due if they exceed the allotted funds.The Adult Day Health Center/licensed caregiver will be responsible for submitting a signed IRS W9 form for payment.Caregivers must submit a Medical Needs Form and have it signed by a medical provider before being determined to be eligible for the Adult Day Health Center Respite Program.Caregivers must submit a government issued ID for both the caregiver and care receiver.As client recipient, I support and uphold transparency and compliance within the Department of Economic Security and Arizona Caregiver Coalition. Our commitment ensures that all staff, volunteers, and program participants meet lawful presence requirements in alignment with relevant laws and regulations.I acknowledge and consent to this information sharing arrangement.
Name of FAMILY CAREGIVER applying for respite*

First NameLast Name
Caregiver Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Phone Number*
Please enter a valid phone number.
Caregiver Email Address*
example@example.com
Caregiver Date of Birth*

MonthDayYear
Date
Caregiver Gender*

MaleFemaleNon-BinaryPrefer not to say
What is the caregiver's level of education?*

Grade School or LessSome High SchoolHigh School GraduatePost High School GraduateCollege DegreePrefer not to say
Are you (the caregiver) a veteran?*

YesNoPrefer not to say
Do you prefer a language other than English?*

NoSpanishOther
Caregiver Race*

AsianBlack/African AmericanNative Hawaiian or Pacific IslanderAmerican Indian or Alaskan NativeWhiteOtherPrefer not to say
Caregiver Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoPrefer not to say
Tell us more about yourself:
What is your (caregiver) relationship to person receiving care?*

Brother / Brother-in-LawSister / Sister-in-LawParent / Parent-in-LawHusbandWifeDomestic PartnerChild (including adoptive/step)GrandchildOther Elderly RelativeNon-RelativePrefer not to sayOther
Do you (the caregiver) reside with the family member you care for?

YesNo
How long have you been providing care?*

Less than 1 year1-2 years3-5 years6-10 years11 or more years
Have you received respite from the Arizona Caregiver Coalition before? (It's okay to apply again!)*

YesNo

Do you or the care receiver 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

Add any comments or questions you have:

Desired Adult Day Health Center or Licensed Caregiver Information
Name of desired Adult Day Health Center
Phone Number of desired Adult Day Health Center
Please enter a valid phone number.
Address of desired Adult Day Health Center

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE READ CAREFULLY AND CHECK EACH ITEM BELOW:
I acknowledge that:*

Completion of this Adult Day Health Center Respite Program application does not guarantee that I will be eligible for the Respite Program.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.
Print your name again*

First NameLast Name
My Signature on this form signifies that all information provided on this form and during any other assessments conducted by the Arizona Caregiver Coalition and the Caregiver Resource Line is truthful and accurate. I further acknowledge that the completion of this Respite Program application does not guarantee that I will be eligible for the Respite Program*

Clear
Any additional notes:
How to Submit Documentation
1. Attach/upload below
2. Email: info@azcaregiver.org
3. 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. This can be found on our website here: https://azcaregiver.org/wp-content/uploads/Respite-Programs-Medical-Needs-Form-1.pdf
Cancelof
Should be Empty:

	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 worsen 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?

ACC Adult Day Health Center 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.

Desired Adult Day Health Center or Licensed Caregiver Information

PLEASE READ CAREFULLY AND CHECK EACH ITEM BELOW: