Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs *Respite Family Needs Checklist

Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs *Respite Family Needs Checklist

Complete this form if your child or youth is age 18 or under and has a diagnosed medical, behavioral, or physical need that requires more care and support than that of their peers.
Parent's Name

First NameLast Name
Child's Name

First NameLast Name
Social Security Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Respite is care that is provided, in or out of the home, for the purpose of providing relief to the family/caregiver from the daily responsibilities of care for the child/youth with special health care needs. Respite services are family-directed, using the respite service provider and location of the family’s choice.
*Contact your care coordinator for more information about respite, ask for the Get Creative About Respite manual, or view it on-line at WWW.FAVOR-CT.ORG
Caregivers available to meet needs

Complete each section
Section 1(and/or):

Child or youth with special health care need has more than one significant physical, behavioral, or complex medical diagnosis.More than one family member living in the home needs extra care and support.
Section 2(or):

Primary caregiver is in good health.Primary caregiver is in poor physical or emotional health.
Section 3:
Section 3Number of adults   available to help care for the child or youth with special health care needs.
Total number   of individuals living in the household.
Total   gross household income.
Section 4(Check off all that apply) Sources of community support during the past 12 months :

Family receives direct funding from the Department of Children and Families (DCF).Family receives direct funding from the Department of Developmental Services (DDS).The child or youth receives Voluntary Services from DCF or DDS.The child received Birth to Three Services.The child or youth received respite services at a DDS Respite Center.The family received a subsidized adoption.The child or youth is on the Katie Beckett Waiver or other waiver.The child is enrolled in TRICARE and the Extended Care Health Option (ECHO).The child or youth has home health aides or nursing services on a weekly basisThe child or youth receives extended day services from school or a community groupThe family received camp fundsThe family received respite fundsReceived regular caregiver support from a community group or foundation
If the family received respite funds. Who from?
If The family received camp funds. Who from?
Please list below any other information you wish to share.
*The Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs is a program supported by the State of Connecticut Department of Public Health. Information is available on the web at www.ct.gov/dph/medicalhome
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Connecticut Medical Home Initiative for Children and Youth with Special Health Care Needs *Respite Family Needs Checklist

Caregivers available to meet needs