Language
English (US)
Caregiver Respite Self Screening 2023
This program is offered with funds from the Arizona Lifespan Respite grant. This is a collaboration of the Arizona Caregiver Coalition with the Department of Economic Security (DES) and the Area Agencies on Aging and their Association (AZ4A). When you submit this form to the Arizona Caregiver Coalition, we will let you know if you meet requirements and are eligible to submit an application.
Family Caregiver Name
First Name
Last Name
Do you live in Maricopa County?
*
yes
no
Phone Number
-
Area Code
Phone Number
Email
example@example.com
What city do you live in?
How do you want to get the application form?
*
Online, we will send a link to your e-mail address
Mail, we will send a paper form
What is your relationship to the person you care for? "I am the ...."
spouse / domestic partner
son / daughter (in law)
sibling (brother, sister, step/adoptive)
Other relative
Are you interested in the day center respite or the voucher?
Adult day center respite (over age 18)
Respite voucher (caregiver makes own arrangements, can be in-home)
Respite voucher while I attend a class or event for caregiver
Emergency respite (medical emergency or need to take a trip)
Not sure
Are you interested in a voucher to help pay for :
Care Navigator
Training
Reimbursement for Activities you do to relax and take a break from caregiving
Not sure, would like to learn more
Home modification and assistive technology
Language other than English? (leave blank if not needed)
Spanish only
How did you hear about us?
Internet search
Facebook
Family member
Agency / case worker
Friend/Neighbor
DES/DAAS Division of Aging
DES/DDD
Media, news, radio
AAA
AARP
Please answer all these screening questions
You (caregiver) and your family member
Yes
No
Do you and the care recipient live together?
Are caregiving duties causing you stress or health issues?
Does the family member need care or supervision most of the time?
Do you work outside the home?
Is the person you care for over 18?
Have you received respite from the Coalition before?
Yes
No
Does the person you care for have any of these services?
Yes
No
Arizona Long Term Care (ALTCS)
Hospice
Veteran's Administration (VA) Aid and Attendance
Developmental Disability Services
Area Agency on Aging respite (ADHC or in-home)
Do you get respite services from any of these programs?
Yes
No
Arizona Long Term Care (ALTCS)
Hospice Medicare benefit with respite in a facility
Veteran's Administration (VA)
Developmental Disability Services
Area Agency on Aging respite (ADHC or in-home)
Other state or federally funded programs or insurance
Do you (the caregiver) help with one or more of these activities regularly?
Yes
No
Personal hygiene, bathing, grooming and oral care
Dressing, making clothing choices and ability to dress's oneself
Eating (feeding the person, not necessarily preparing food)
Maintaining continence (help to use the bathroom)
Transferring (moving from seated to standing or help in/out of bed)
Medication Management
Special care beyond parenting (should be marked "Yes" if the care receiver is under 18)
Other
Notes
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Leave blank. For office use only.
Respite voucher application sent
Day Center application sent
Follow-up 1
Follow-up 2
Notes
Submit
Should be Empty: