Thank you for applying for an Easterseals respite voucher program. Please be sure you are completing the correct form. This application is for the Child and Adolescent Caregiver Respite program. To be eligible for this program, the child or children for whom you provide care:
must be 17 years of age or younger
must have a behavioral or mental health issue or developmental disability as noted by a medical diagnosis, IEP and/or 504 plan
must not yet be eligible for/receiving respite services through the Division of Developmental Disabilities Services (DDDS)
must reside in the same home, with you as a primary caregiver
All information in this application is confidential, however, the Child and Adolescent Caregiver Respite program is partially funded through the Division of Prevention and Behaivioral Health Services (PBHS), and therefore, we are required to share information from this application with them.
Please read through this application carefully. If you have any questions while you complete this form, or prefer to do it over the phone, please call our office at 302-221-2087.