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
PhoneEmail
Ohio Rise Care Coordinator
Name*

First NameLast Name
Phone*
Phone NumberFormat: (000) 000-0000.
Email
example@example.com
PhoneEmail
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
PhoneEmail
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*
Aetna OhioRiseBuckeyeCareSourceMolinaParamountUnited Health CareHumana
Additional Child Information
YesNo
YesNo
YesNo
Please list
YesNo
Please list
YesNo
Please explain
Difficulties Self RegulatingEating DisorderEloping/running away/AWOLProperty DestructionPhysical AggressionSelf-HarmSexual BehaviorVerbal AgressionWithdrawnSuicidal ideation/attemptsHomicidal ideation/attemptsSUD issuesUnable to self-protectIssues as schoolIssues with family membersNone of the above
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