Respite Application – Hilltop Ranch

Apply For Respite Care

Please be as honest as possible as you answer these questions, and let us know if you have any questions as you complete the application. Once you've submitted your application, we will be in touch to discuss next steps within one week.

Respite Application

Applicant Information

Applicant First Name

Applicant Last Name

Date of Birth

Sex

Primary Disability

Other Disabilities

Primary Guardian Details

Please provide information about one of the applicant's parents or legal guardians.

First Name

Last Name

Phone Number

Email

Address Line 1

Address Line 2

City

State

Zip Code

Country

Secondary Guardian Details

Please provide information about the applicant's other parent or guardian.

First Name

Last Name

Phone Number

Email

Address: Please leave blank if it's the same as above.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Emergency Contact

Please feel free to leave this blank if the emergency contacts are the two people listed above.

Name

Phone Number

Relationship to Applicant

Email

Activities of Daily Living

Please check the ADL(s) with which your applicant needs assistance.

Grooming

Bathing/Showering

Oral Hygiene

Skin and Hair Care

Diet and Nutrition

Eating

Hydration

Mobility

Toileting

Telephone Use

Medication Management

Money Mangement

Dressing

Setting boundaries with others for personal safety

Time Management

Behavior/Social Interaction

Please check all that apply or have occurred in within the past year.

Pulls Hair

Hits/Scratches Others

Bites

Destructive

Physically Aggressive

Threatens

Curses/Verbally Abuses

Lies

Steals

Harms Self

Invades Private Spaces

Wanders/Runs Away

Screams

Bangs Head

Inappropriate Sexual Behavior

Sexually Passive

Inappropriate Use of Technology

If you checked any of the boxes above, please provide further information and describe how often these behaviors occur.

Medical Information

Please describe any medical conditions and how they are managed.

Please describe any psychological conditions and how they are managed.

Please detail all current medications, including information about dose, route, time given, and reason.

Does the applicant have any allergies or dietary restrictions? If so, what are they? (Please note that you will be required to provide EpiPens for allergies.)

Equipment/Appliances Needed

Vision Correcting Glasses

Hearing Aids

Dentures

Retainer

Cane/Crutches

Walker

Wheel Chair/Power Chair

Current Primary Provider

Name

Office Name

Phone Number

Address

Additional Information About Applicant

Please specify if there are specific dates you're seeking respite care. If you're flexible, what is the duration of care you're seeking?

Please describe the applicant’s social/emotional state most of the time (for example: withdrawn, hyper-verbal, frustrated, sociable, even-tempered, etc.).

Please describe the applicant's communication abilities.

Does the applicant exhibit any difficult or disruptive behaviors? If so, what is the best way to address them?

Has the applicant ever attended overnight camp or been away from home and family for several days? If so, how did the applicant handle this change?

Please describe activities, settings, or situations that the applicant strongly dislikes or struggles with.

Does the applicant have any history of inflicting harm to themselves, others, or property? If so, please describe.

Are there any individuals who are NOT allowed to visit or contact your applicant?

What are positive reinforcements and suggestions which effectively encourage participation in activities? (I.e., how to word a request, lead time needed before compliance is hoped for, etc.)

Are there any safety concerns we should be aware of? For instance, would the applicant attempt to operate oven, stove, etc. without supervision? Would they activate fire alarms? Would they leave the Lodge of their own accord?

Conclusion

If there is any further information which could influence the care, health, or well-being of this individual at Hilltop Ranch, please explain:

Do you certify that, to the best of your knowledge, the provided information is true and accurate?

Yes

No

Want to live at Hilltop Ranch?

Our application is now live.

We currently have a few spots remaining. Once all eight spots are filled, new applicants will be added to our waitlist.