| Date of Proposed Respite |
|
| Date RCI was provided to Respite Provider: |
|
| Child Name: |
|
| Date of Birth |
|
| Age: |
|
| Gender: |
|
| Level of Care |
|
|
RESPITE PROVIDER INFORMATION:
|
| Name of Respite Provider |
|
| Respite Provider's Email Address: |
|
| Respite Provider's Address: |
|
| Respite Providers Contact Number: |
|
| Secondary Contact Number: |
|
| Is Respite Provider a licensed foster parent? |
YES
NO
|
|
CONTACT INFORMATION:
House of New Hope staff can be reached at (888) 200-1296 around the
clock.
|
| Custodial Agency: |
|
| Who is the assigned Clinician? |
|
| Foster Parent(s) and Contact #: |
|
|
HEALTH / MEDICAL INFORMATION:
|
| Check all that apply: |
No current medical/health problems
Current medical/health problem
Special dietary restrictions
|
| Explain any YES responses: |
|
| Additional Medical/Health related information: |
|
|
BEHAVIORAL INFORMATION:
|
| Check all that apply: (past 12 months) |
No behavioral problems
Hurting animals
Fire setting
Suicidal gestures/attempts
Sexual aggression/acting out
Physical aggression
Criminal activity
Verbal aggression
|
| Explain all YES responses |
|
| What negative behaviors can the respite provider expect and under what
conditions? |
|
| Describe what de-escalation techniques work when the child
misbehaves: |
|
| Additional behavioral related information |
|
|
EDUCATIONAL INFORMATIONAL:
|
| Check all that apply: |
No educational concerns
Child will be attending school during respite
Child has been suspended or expelled during school year
Child has been truant during the school year
Child will require assistance with homework
|
| Explain all YES responses: |
|
| Additional education related information: |
|
|
MENTAL HEALTH INFORMATION:
|
| Check all that apply: |
No mental health issues or concerns
Child has been the victim of trauma and/or maltreatment
Child is prone to depression
Child is prone to anxiety
Child is prone to tantrums
Child is prone to challenging behaviors
|
| Explain all YES responses: |
|
| Additional mental health information: |
|
|
MEDICATION INFORMATION:
|
| Check all that apply: |
Child does not take medication
Child is currently prescribed medication
Child is currently taking over-the-counter medication
|
| Provide the medication name, dose, times to be given, how the medication
is to be taken, and the purpose of the medication: |
|
| Additional medication information: |
|
|
VISITATION INFORMATION:
|
| Check all that apply: |
No visitation
There is someone restricted from contacting the child
There is someone restricted from visiting the child
The child will have a planned visitation during the respite
|
| Provide the name and relationship of restricted
contacts/visitors: |
|
| Provide the planned visitation plan including date of visit, start and end
time of visit, location and address of visit, whom will the child be visiting, and
transportation arrangements: |
|
| Additional visitation information: |
|
|
APPOINTMENTS AND MEETINGS:
|
| Check all that apply: |
Child has no scheduled appointments or meetings
Child has a scheduled appointment or meeting during this respite
|
| If YES, what is the date of the appointment, the start and stop time, the
location and address, the reason for the meeting, and the transportation
arrangements: |
|
| Additional appointment or meeting information: |
|
| Sign your name and today's date at the bottom of this page attesting that
you received this information PRIOR to the respite. |
|
| FAX this signed form to (888) 246-0445 or EMAIL signed form to
bpack@houseofnewhope.org |
|
|
