Respite Eligibility Screening

Client resides in North San Diego County (Highway 56 –Fallbrook)

YesNo

Client has been approved for Respite hours by the San Diego Regional Center

YesNo

Client and Family understand that UCP provides hours in 2 or4-hour shifts during Monday- Friday. Saturday by request, closed Sundays.

YesNo

Client's Family understands that documentation will be required to enroll, including: 1. Client’s most recent physician report/physical 2. Proof of negative TB test 3. Client's current SDRC Care Plan 4. Client's current medication list 5. A current photograph.

YesNo

Client and Family understand that the first step is to schedule a home visit/in-take appointment.

YesNo

Client and Family understand this is in-home supportive care. Caregiver will come to their home and cannot drive Client. Caregiver will provide enrichment activities and care following our Code Ethics.

YesNo

Client and Family understand this is non-medical supportive care. Non-medical means UCP Caregivers can assist with care plan goals and creating meaningful activities, toileting, feeding, hydration, pass medication (but not pour). Our Caregivers cannot provide: diabetic care/shots, wound care, catheter or colostomy bag care, suppositories, feeding tube care, ventilator/oxygen care, or care for those with self-injurious or combative behaviors. Showering and dressing is only in the event of a toileting incident.

YesNo

Caregiver Selection

Client and Family would like a UCP Registry Caregiver to provide Respite CareClient and Family has selected a Caregiver for the hours (A Caregiver who is family/friend that knows the client but does not reside at the same address. Must be willing to become a UCP Employee, they will complete UCP Employment screening, including Live Scan Fingerprinting and will receive ongoing paid Caregiver training)

Client's First and Last Name

Client UCI Number

Client Age

Client City (i.e. Escondido)

Approved Number of Respite Hours Per Quarter

Please list name of any day program or school the Client is attending

Name of Person to Contact for Enrolling Client

What is their Relationship to Client (i.e. Mother)

Contact's Phone Number

Contact's E-Mail

Best Time of Day to Contact

Name of SDRC Case Manager

E-mail of SDRC Case Manager

Best Phone Number for SDRC Case Manager

Note to UCP Respite Coordinator (Please be Mindful of HIPPA)

Thank you for completing this form. UCP will be reaching out to the Client and their Family within 5 Business Days

We look forward to welcoming you to the UCP San Diego County family! Learn more about us at www.ucpsd.org

Tip: If the Client is ambulatory, we encourage families to register their loved one with the Sheriff Take Me Home program.