IN-HOME RESPITE SERVICES INTAKE FORM
Are you seeking respite for yourself or someone else?
Yes, myself.
No, someone else.
Following is a small intake form for Plumas Rural Services to gauge your specific needs and the best way to contact you.
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Primary Caregiver Information:
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Information
How many hours of Respite Care that Plumas Rural Services (PRS) will be providing as authorized by Far Northern Regional Center?.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have someone in mind who would be interested in becoming an employee of Plumas Rural Services to provide the Respite care?
Yes
No
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Plumas Rural Services’ In-Home Respite Staff is authorized to seek emergency medical care if necessary. Client would be taken to the nearest emergency room or 911 would be called.
Yes
No
Additional PRS Services
Have you heard of the following programs that PRS provides for folks with disabilities?
Early Start Family Resource Center: A service that provides resources and support to families with infants and toddlers age birth to three who are, or may be at risk, for disabilities or developmental delays.
Yes
No
Would you be interested in getting more information about the Early Start Family Resource Center?
Yes
No
Family Empowerment Center: This service providers information, training, supportand advocacy to parents and guardians of children and young adults with ANY disabilityin Lassen, Modoc, Plumas and Sierra counties.
Yes
No
Would you be interested in getting more information about the Family Empowerment Center?
Yes
No
A.L.I.V.E.: ALIVE provides training and support for adults with intellectual and developmental disabilities. Trained staff and a supportive group environment enable participants to hold paying jobs, become involved in community activities, use community resources, increase independent living skills and develop self-advocacy. ALIVE is committed to helping people live productive and enriching lives.
Yes
No
Would you be interested in getting more information about the A.L.I.V.E. program?
Yes
No
Are you interested in receiving emails with applicable information from Plumas Rural Services; for example: events, information from the State for people with disabilities, etc?
Yes
No
Additional Information
Submit
Should be Empty: