Office Use Only      4-2002

                                                                                                                                                                ____________Date Received

                                                                                                                                                ____________Date Entered

Nebraska Respite Network-Across the Lifespan                                        

 

Respite Provider Application

Please provide the following information about yourself, as an individual providing respite.

 

 

Provider Name ____________________________________________________________________________________

 

Address ____________________________________ City ___________________ State ________ Zip ______________

 

Phone (Work)  _____________________   Home __________________________  Cellular _______________________

 

FAX # ______________________   Toll-free # ________________________  TDD/VTDD# _______________________

 

E-mail Address  ____________________________________ Internet Address _________________________________

 

 

  1. What populations do you serve?  (check all that apply)

                         _____ Alzheimer’s                                           _____ Medical Needs

                        _____ Behavioral Disorders                           _____ Mental Illness

                        _____ Chronic Illness                                       _____ Physical Disabilities

                        _____ Developmental Disabilities                 _____ Risk of Abuse and / or Neglect

                        _____ Frail Elderly                                           _____ Other _________________________________

                       

  1. What age group(s) do you serve?  (check all that apply)

                         _____ 0-2 years                                               _____ 19-64 years

                        _____ 3-5 years                                                _____ 65 & over

                        _____ 6-18 years                                             _____ All ages

 

  1. How are you paid for your services? (check all that apply)

                        _____ Medicaid Waiver                                               _____ Private Pay

_____ Respite Subsidy                                                _____ Foster Care

_____ Social Services Block Grant                            _____ Early Intervention

_____ SSI / Disabled Children’s Program                 _____ Medically Handicapped Children’s Program

_____ Disabled Persons & Family Support              _____ Other __________________________________

 

  1. On average, how much do you charge for respite services?

                       $_____ Average Hourly Fee                    _____ Volunteer / Accept no fee           

_____ Accept Donations                        _____ Sliding Scale

_____ Other (please specify) ____________________________

 

  1. Are you willing to provide respite services during special hours?   If so, when?  (check all that apply)

                        _____ Evenings                                                 _____ Emergencies

                        _____ Overnight                                                _____ Extended periods (specify) __________________

                        _____ Weekends

 

  1. Where do you provide respite?  (check all that apply)

_____ In the client’s home                               _____ Hospital

                        _____ In my home                                            _____ Nursing Home Facility

                        _____ Adult Day Care Facility                        _____ Other __________________________________

                        _____ Child Care Facility

              

  1. While providing respite or in addition to providing respite, is there any other assistance you provide or are willing to provide?  (check all that apply)

                         _____ Assistance with bathing                       _____ Speech Therapy

                        _____ Chores (errands)                                   _____ Occupational Therapy

                        _____ Light housekeeping duties                   _____ Respiratory Therapy

                        _____ Physical Therapy                                   _____ Other _________________________________

                       

  1. What requirements must clients meet in order to be eligible for your respite services? 

          (e.g. complete approval process, qualify based on income) __________________________________________

__________________________________________________________________________________________

 

  1. What intake procedures, if any, do families need to follow in order to receive respite services?                                                                                                                       

          (e.g. fill out an application, show proof of income) ________________________________________________

__________________________________________________________________________________________

 

  1.  What is your primary language? ____________________ Other languages spoken?  ______________________

 

  1.  What geographic area(s) do you serve? (list towns, cities, or counties)   ________________________________

           ___________________________________________________________________________________________ 

 

  1. Do you have a waiting list of families who have requested respite services?   YES _____  NO _____

If so, how many families are on your waiting list? _________________________________________________

 

  1.  List any specialized training you’ve had? (Please explain)____________________________________________

__________________________________________________________________________________________

 

  1.  Are you willing to share that training with others?  YES _____ NO _____

 

  1.  How many years have you been providing respite?

 

_____ 0-1 years                                    _____ 7-10 years

_____ 2-3 years                                    _____ 11 years or more

_____ 4-6 years           

 

 16. What distance are you willing to travel?

 

_____ Less than 10 miles                        _____ 26-50 miles

_____ 11-25 miles                                   _____ 51 miles or more

 

 17. Is your home or agency accessible (barrier-free)?              YES _____ NO _____

 

 18. Would you be willing to provide references?                      YES _____ NO _____

 

 19. Would you be willing to offer transportation to a client?   YES _____ NO _____ 

 

 20.  Do you want your name to be available for referrals through the Nebraska Health and Human                                            

   Services Statewide Respite Provider Database to provide respite services to families?  YES _____  NO _____ 

 

I, _______________________________, give the Nebraska Lifespan Respite Services Program permission to
enter information as needed, into the Nebraska Health and Human Services Statewide Respite Provider Database.

 

_______________________________ Signature ________________ Date

 

Comments or Suggestions (please use separate sheet if necessary): __________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

 

Cheryl Albright

P.O. Box 509

Loup City, NE 68853

calbright@cennecs.org