Hope Respite Care

Hope Respite Application

 

Summer 2019

Dear Primary Caregiver,

Caregiving is a demanding job. As a caregiver, you need occasional breaks so you can tend to your own needs and the needs of other family members. You cannot pour from an empty cup.

Our respite program can provide short-term relief for a few hours, a day, a weekend, or sometimes longer. While respite care is not a substitute for ongoing child care or school, Hope is providing a way to support families who take care of their loved ones at home.

Below you will find our respite application. This service is of no cost to you, but candidates for respite must be thoroughly reviewed and approved to ensure appropriate care during your child’s stay. Our top priority is safety; for your child and for the children we already serve. We want your respite time to be a time in which you can feel at peace and trust that your child is well cared for. In order to gain that assurance, our application must be completed candidly and thoroughly. Hope is a highly structured place with great resources; however, no one likes surprises. We will ask questions. We will search for clarity. We will be thorough. We will be taking care of your most precious possession and we don’t take this responsibility lightly.

Please complete the application in its entirety. Any incomplete applications will be returned by mail. If you have any questions at all, please reach out to me directly.

Sincerely,

Amanda Brott, MS, BCBA
Chief Operating Officer and Executive Director
Hope Academy Programs
217-585-5437 x165
abrott@hope.us

Hope Respite Application

 

Application Checklist
Please include all documents as outlined below; without these documents, your application will be incomplete and cannot be processed. Email documents to abrott@hope.us if filling out the online form. 

o Complete Application
o Physician’s Health Form (signed by physician)
o HIPAA Policy and Procedure
o Current IEP
o Behavior Plan, Seizure Protocol, Allergen Protocol (if applicable)
o Full List of Medication Including Dosage, Time Administered, and How Administered

Please fill out the form here and submit via mail to Amanda Brott at 15 E. Hazel Dell Lane, Springfield, IL 62712 or fax to 217-529-8234 or scan and email to abrott@hope.us. You can also pick up forms and packets at the following locations: 

The Hope Learning Academy Springfield 
15 E. Hazel Dell Lane, Springfield, IL 62712

The Autism Clinic at Hope
5220 S. 6th Street Rd., Springfield, IL 62703

Hope Inclusion Cafe
3252 Ginger Creek Drive, Springfield, IL 62711

Hope Cafe
5220 S. 6th Street Rd., Springfield, IL 62703

Hope Respite Application

 

About us

To provide state of the art services in the most inclusive environment to encourage persons to fulfill their individual potential through evidence based treatment, advocacy and community education.

Contact

Hope

15 East Hazel Dell Lane
Springfield, IL 62712