Step One Regional Consultation Program
6 Fort St. Quincy, MA.02169
Tel: 617-774-1040 Fax: 617-847-0915

RESPITE FUNDING REQUEST FORM

Child’s Name: _____________________________________ DOB: ____________

Parent/Guardian Name: _________________________________ Phone: ____________

Address:________________________________________________________________

EI Program: _____________________________________________________________

EI Program Contact Person:________________________________________________

Is the child a MassHealth Recipient? Yes ______ No _____

If so, what type:
Standard ________
Common Health ________
Kaileigh Mulligan ________

Number of Family Members: __________

Family Income: $ _____________
Income must be provided in order
to determine priority status.
Failure to complete this question
and include verification will result in
automatic DENIAL.

Please state child’s diagnosis, level of functioning, amount of specialized care needed daily, adaptive needs or equipment, any extensive health/medical needs or multiple disabilities.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

How would you like to use the approved money/hours (ie. one time, weekly, monthly)?
Please state the hourly rate, if available: $_____________/hour

Do you have an identified provider? ______ Yes _______ No
If yes, Name: __________________________________
Relationship to child: ____________________________
Does your provider need any special training? ______ Yes _______ No
If yes, what training (ie. CPR, First Aid)? ______________________________________
Do you need assistance finding a provider? ______ Yes _______ No

Signature of Parent/Guardian: _________________________________ Date:_________

Signature of Referring EI Provider: ___________________________ Date:_________

For Review Purposes Only – Do Not Write in the following Area