United Way Respite Service Documentation Form

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United Way Funded Respite Service Documentation
Consumer’s Legal Name:
_ _ / _ _ / _ _
Date of Birth:
(include nicknames used in summary)
_ _ / _ _ / _ _
Date of Service:
Start Time: _ _ : _ _
End Time: _ _ : _ _
Individual 1:1
Arc Group Respite
In-Home Group Respite
Getaway Respite
Type of Respite:
# of Siblings Present during service* :
Family Fee (hourly): $
Total Family Cost: $
Location of Service (check all that apply – if visiting more than one location, document when and where in summary):
Consumer’s Home
Community
(list site i.e. Walmart on Edgewood or Panera NE):
Summary of Respite Service:
Approximate
Must be in complete sentences and remain objective.
(i.e.
Activity Length
What did consumer do? How did consumer respond? What did staff do?)
(ex: 1500-1530)
To be completed at the end of the respite session or while consumer is sleeping.
Continue on back if more room is needed. DSP & Primary Caregiver/Consumer must complete & sign back.

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