Respite Care Referrals

Respite Care Referral Form

of for Parent/Guardian

Child's Name

First

Last

DOB

Parent/Guardian

First

Last

Phone

Screening for Eligibility (*Documentation for each requirement must be provided within 5 days of screening):

Must have a diagnosis of a developmental disability or are considered high risk because of developmental delay in cognition, language, or physical development and/or a physical or genetic anomaly associated with developmental disability
Child must be between the ages of 3 and 21
Must reside in Broward County

Comments

*Families who meet and provide proof of all required eligibility criterion will be accepted on a space available basis.

*For more information call Savannah Woodhall, Program Coordinator at: swoodhall@arcbroward.com (954) 746-9400 ext. 1109