Lesia's Land of Love

Lesia's Land of Love

Respite Intake Form
Full Name*

First NameLast Name
Preferred Name/Nickname
Date of birth*

MonthDayYear
Date
Age*
Gender*

MaleFemaleOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Parent/Guardian 1 name*

First NameLast Name
Relationship to child*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian 2 name

First NameLast Name
Relationship to child
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
Name*

First NameLast Name
Relationship to Child*
Phone Number*
Please enter a valid phone number.
Who is authorized to pick up the child (list all names)*
Respite Care Details
Reason for respite care*
Respite start date and time*
Respite end date and time*
Special instructions for drop-off/pick-up
Health & Safety
Any known allergies*

YesNo
If yes, please list:
Is the child currently taking any medications*

YesNo
If yes, please list (include dosage, route of administration, time to be administered, purpose of medication, possible side effects):
Special health conditions or needs:*
Specific allergic reactions to watch for
Steps to take if an allergic reaction occurs
Special dietary needs*
Seizures*

YesNo
If yes, describe type, frequency, and management
What interventional steps should we take?
When should we call you regarding symptoms or failure to respond to treatment?
When should we consider that the condition requires emergency medical care or reassessment?
Topical ointment permission*

A&D or other diaper rash ointmentBubble bath and/or lotionSunscreenInsect repellent
Recent hospitalization? if yes, please describe*
Does the child have a history of:*

Running awayInjuring themselvesInjuring othersDamaging property
Any Bruises or injuries present upon arrival?*

YesNo
If yes, please describe:
Daily routine & preferences
Usual wake-up time*
Usual bedtime*
Nap schedule, if applicable*
When did your child last eat?*
Bathing preference/need?*

YesNo
If yes, please explain
Sleeping arrangement recommendations/requests (Please note that child may share a bedroom with an age-appropriate child of the same sex)*
Comfort items*
Preferred activities*
Activities to avoid*
Information regarding your child with exceptional needs
Definition of Condition (What is the medical definition of the condition that your child has?)*
Manifestation of Condition (What are the specifics of how the condition is manifested in the child?)*
Treatment (What treatment has the child had for this condition? What treatment is the child currently undergoing? Who provides treatment?)*
Triggers (What home, school, and community situations trigger inappropriate behavior?)*
Early Warning Signs: (What initial behaviors signal that the child is becoming agitated/anxious?)*
Preventive Measures (How can the environment, activities, attention, be structured to prevent problems or altered to effect a positive change if problems are beginning to occur?)*
Avoid (Which behavior management techniques make the situation worse rather than better?)*
Escalated Behaviors (What happens when the child escalates? How quickly does escalation occur?)*
Interventions That Are Most Useful (What interventions have proven to be most useful in home, school, and community settings?)*
Call Order (In what order and under what circumstances for each are police, social worker, and/or parents to be called?)*
Is there a plan for managing the child's behaviors at home*

YesNo
If yes, please explain
Is there anything else we should know about your child to provide the best possible care?
I, blanks the legal gardian of blank , do hereby grant permission for my child to attend respite care provided by Lesia’s Land of Love Receiving Home.

I understand while respite care, the provider will make reasonable efforts to ensure my child’s safety and well-being during the duration of care. I agree that respite services may end due to the child’s illnesses and/or escalated, disruptive behaviors that conflict with the safety of my child and/or other children within the stay at Lesia’s Land of Love Receiving Home.

It is further understood that after contacting you, the child will be sent home.
I authorize the respite care provider to:
·      Provide necessary care and supervision.
·      Administer medications as outlined above.
·      Seek medical attention in case of emergency.
·      Contact me immediately in the event of an emergency or if additional instructions are required.
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Lesia's Land of Love

Parent/Guardian Information

Emergency Contact

Respite Care Details

Health & Safety

Daily routine & preferences

Information regarding your child with exceptional needs