Memory Care at Allen Brook Day Respite
Respite Participant Name
*
First Name
Last Name
Caregivers Name
*
First Name
Last Name
Caregiver Phone Number
*
Phone number with Area Code (example: 802-859-8886)
Caregivers E-mail
example@example.com
Caregivers Address
For communication purposes only
Payment Source?
*
Please Select
Medicaid
Private Pay
If Medicaid, please list the name, number and email of your case manager.
Has the participant received a formal dementia diagnosis from a licensed medical professional?
*
Please Select
Yes
No
Is the participant at risk of having to move (to a hospital, assisted living, nursing home) without respite day support?
*
Please Select
Yes
No
If yes, please explain why the participant is at risk of needing to move:
How many days a week are you looking for respite care?
*
Please Select
1
2
3
4
5
How many hours per day are you interested in respite care?
*
Please Select
1 hour (minimum)
2 hours
3 hours
4 hours (maximum)
What days of the week and times of day are you interested in respite care? ~Days of the week available: Monday, Tuesday, Wednesday, Thursday, Friday ~Times available: 10:00 am - 2:00 pm, in 1 hour increments
Please list all days of the week and times you are interested in respite care.
Does the participant take prescription or over the counter medications between the hours of 10:00am - 2:00pm
*
Please Select
Yes
No
If yes, please list all medications the participant needs to take between the hours of 10:00 am - 2:00pm.
What is the participant in need of for support at this time?
How did you learn about the Memory Care at Allen Brook day respite program?
*
Please Select
Primary Care Provider
Age Well
SASH
Case Manager
Friend or Relative
Media
Flyer
Comments:
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