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Family Application

As a parent or guardian who cares for an individual with a disability with DSPD Medicaid waiver funding, you may struggle to find someone who can help care for your loved one. If you would like some help tackling the task of finding, hiring, and training respite workers, then apply to have us help you connect with a respite worker we have recruited and trained through a grant from DSPD.

Earn up to $1,000 by, among other requirements, completing the application, hiring a worker, and employing them at least through the Summer!

This program is currently for residents of Salt Lake, Utah, Davis, Weber, Cache, Iron, Washington, or San Juan counties only.

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Do you have a child/individual on the DSPD Medicaid Waiver, or are you on the DSPD waiting list with one-time funding? *

* Required

Are you willing to complete our 2-hour online employer training modules? *

* Required

Are you willing to attend an online meeting for the parents or guardians who are participating in the UtahRespite.Care program and complete a feedback survey? *

* Required

Are you currently using DSPD-funded Self-Administered Services (SAS), or are you willing to sign up to use it? *

Self-Administered Services (SAS) includes hiring your own employees and using a fiscal agent. Although UtahRespite.Care participating families must use the SAS model or Give.Care, Caregiver Compensation and SAS can be used together. View our Onboarding Training to learn more about SAS. If you’re using Giv.Care, select "Yes".

* Required

Does your current DSPD budget have the RP1 Code and/or SL1 Code? If not, will you work with your support coordinator to add these codes? *

If you’re using Giv.Care, select "Yes".

* Required

In order to have an ideal match with trained respite workers in your area, are you okay with us creating a secure online profile for you that can only be viewed by participating UtahRespite.Care respite workers who are looking for work? *

Information on your profile will include your first name, preferred contact method (email and/or cell phone number), county, city, and days and times you need respite care. In addition, your child’s preferred fun activities, age, gender, preferred respite worker gender, type of care needed, and their primary language is included. A cute photo of your child can also be added if desired!

* Required

Do you want a refresher on the hiring process and paperwork for your new DSPD respite and supported living workers? *

* Required

Who is your fiscal agent? *

Select all that apply.

* Required

Which of the following days and times do you need respite care?

Select all that apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What is the gender of your child who is on the DSPD Medicaid Waiver? *

* Required

What is the birth year of your child who is on the DSPD Medicaid Waiver? *

This is used for program reporting and matching purposes.

What is the primary language that you speak at home? *

* Required

What is your child’s primary diagnosis? *

Select all that apply.

* Required

Which word best describes your child's disability? *

* Required

Which word best describes your child's behaviors? *

* Required

What kinds of tasks does your child require help to complete?

Please Note: UtahRespite.Care does not train respite workers to perform toileting, medical, or transferring tasks. If your child requires this level of care, you will need to train your hired respite workers or consider hiring a CNA. Respite worker profiles will indicate whether or not they are comfortable learning how to perform these tasks. Select all that apply.

* Required

Does your child prefer to work with a female or male respite worker? *

* Required

What types of activities does your child like to do?

This information will be displayed on your profile.

Is there any other information that will help us know about your situation or what you're looking for in a respite worker?
Please provide your contact information. *

This is used to provide you with support and connect you with respite workers.

Please select all the contact methods you want to be displayed on your members-only website profile on UtahRespite.Care. *

Select at least one.

* Required

Select a headshot photo of your child if you want respite workers to see a picture of your child on your online profile.

Formats: PNG, JPG, or JPEG  |  File Size: Up to 8MB  |  Square Photo Recommended

Select File

* Required

For grant requirements, do you own your own home, rent your home, or are you living with someone else? *

* Required

For grant requirements, what is your annual household income? *

* Required

How did you hear about UtahRespite.Care? *

Select all that apply.

* Required

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