Lifeworks Behavior Respite Service Request

Behavior Respite Service Request
In order for us to better assist you accessing treatment services; please fill out the following Behavior Respite service request form. If questions (or sections) do not apply to you and/or your child, please enter "N/A."
Request Date

MonthDayYear
Parent Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please indicate your preferred method of contact
Ohio Rise Care Coordinator
Name

First NameLast Name
Phone
Phone NumberFormat: (000) 000-0000.
Email
example@example.com
Please indicate your preferred method of contact
Secondary Emergency Contact
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone
Phone NumberFormat: (000) 000-0000.
Email
example@example.com
Please indicate your preferred method of contact
Child Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Diagnosis
Preferred Pronouns
Gender at birth
Preferred Name
Race/ethnicity
Gender Identity
Spirituality/Religion
Primary Mode of Communication
School
Grade
Medicaid Number
Medicaid Plan
Additional Child Information
Currently involved with Ohio Rise?
Has behavior respite been added to their care plan?
Currently on medication?
Please list
Any allergies?
Please list
History of Trauma?
Please explain
Any of the following behaviour challenges?
Comments on behavioral challenges
Any special needs/accommodations to be aware of?
Child's likes, hobbies, interests?
Child's dislikes?
Child's triggers?

Day/Hours Available for Respite (Weekday)

Rows	Evening(4pm-7pm)
Tuesday
Wednesday
Thursday
Friday

Day/Hours Available for Respite (Weekend)

Rows Morning(9am-12pm) Midday(1pm-4pm)

Saturday
What are the primary reasons for seeking Behavior Respite services
Should be Empty:

Rows	Morning(9am-12pm)	Midday(1pm-4pm)
Saturday

Behavior Respite Service Request

Parent Information

Ohio Rise Care Coordinator

Secondary Emergency Contact

Child Information

Additional Child Information