C.A.E. Behavioral Health - Respite Care Request Form

CAE Respite Care Request Form

Emergency Respite Care for Children & Youth
This request does not guarantee child respite care services. Upon approval, you will receive a confirmation email with the name and phone number of the designated CAE Mentor.
Name of Parent/Guardian*

First NameLast Name
Phone Number*
Email*
example@example.com

Requested Schedule of Care

	Child's Name	Child's Age	Child Sex	Month	Day	Time Start	Time End
1
2
3
4

Please state reason for needing care services*
Do you attend weekly CAE group and/or counseling sessions?*
If you answered no above, you are unfortunately not eligible to receive respite care through the CAE Behavioral Health Network.

Please contact Traci Gregory at (866) 961-2239 ext. 7 to reinstate your eligibility or enroll in the CAE Behavioral Health Network.
Powered by Community Arts Experience, Inc. (CAE)
Should be Empty: