Take me to :

respiteservices.com

My respite plan

Here is a form that you may wish to use when planning your respite needs throughout the year.

You may print a copy of the form: My Respite Plan

Respite Funds: $__________

Special Service at Home Funds:  $__________

Other: $ __________

 

Number of hours of respite available to me (is the total number of hours divided by the Respite contractor rate I wish to pay)

 

How I plan to use my respite hours:

 

My regular weekly respite (what do I need to do?   What would I like to do?)

Monday

Tuesday

Wednesday

Thursday

Friday

Total hrs

Total hours

 

 

 

 

 

 

 

 

 

 

 

 

 

Total number of hours x 52 weeks

Regular weekend respite (what do I need to do?  What would I like to do?)

Saturday

Sunday

Total hours per weekend

Total hours

 

 

 

 

Total number of hours x 52 weeks

 

Do I need to plan for school and/or additional respite for summer holidays?

(over and above regular weekly respite)

Monday

Tuesday

Wednesday

Thursday

Friday

Total hours per week

Total hours

 

 

 

 

 

 

 

Total number of hours  x 10 weeks

 

Do I need additional respite for Christmas ?(over and above regular weekly schedule)

Monday

Tuesday

Wednesday

Thursday

Friday

Total hours per week

Total hours

 

 

 

 

 

 

 

Total number of hours x 2 weeks

 

Do I need additional respite for March Break ?(over and above regular weekly schedule)

Monday

Tuesday

Wednesday

Thursday

Friday

Total hours per week

Total hours

 

 

 

 

 

 

 

Total number of hours x  1 week

 

Other  needs? (school: pd day/exam days, medical appointments, special occasions….)

Number of hours/day

Number of days

Total hours

Total hours

 

 

 

 

Total number of hours

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