St. Clare's Homes - Respite Referral Form

St. Clare's Homes are contracted with the NJ Division of Child Protection & Permanency (DCP&P) to provide transitional housing and comprehensive services to children with specialized medical needs.

Links to Resources to help DCP&P match a case with St. Clare's Homes:

The form below can be printed, completed, and submitted to Debra Leib via email at dleib@stclaresservices.org or fax at (973) 242-3583.  Debra can also be contacted at (908) 351-8746.

RESPITE REFERRAL FORM

Child’s Name: _______________________________________
Date of Birth: ________________________________________
Respite Stay Dates: ___________________________________

Diagnosis: __________________________________________

Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________
Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________
Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________
Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________
Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________
Medication: ____________  Dosage: _________  Time(s): ________  Route: ______________


Diet/Routine
☐Formula/Milk & Schedule:  ____________________________                                                                            
☐Baby Food  - Stage______
☐Regular Diet                                    ☐Pureed                                            ☐Table Food
☐Feeds Self                                       ☐Feeds Self with Help                      ☐Total Feed
☐Tube Feeding: (List feeding times)                                 
☐Diaper  - size________                   ☐Potty Trained
☐Ambulates Independently                       
☐Requires Adaptive Equipment: If yes, please list:

Food Likes: ________________________________________
Food Dislikes: ______________________________________
Food Sensitivities: ___________________________________
Food Allergies: ______________________________________

Sleeping Routine
Morning awake time: __________________
Nap time(s): _________________________
Bedtime: ___________________________
Nap and Bedtime Routine: ______________________________

Activities
Please list the child’s favorite indoor and outdoor activities:

Calming Techniques:
Please list any calming/soothing techniques if the child is crying or upset:

Child Knows HIV/Medical Status: Yes ☐ No ☐        N/A
Comment:

Visitation Plan:
Will there be any visitors, including therapists, that will visit at St. Clare’s during this respite?
Yes ☐ No ☐        If yes, please complete information below:
Date: _______  Name: ____________  Relationship to Child: __________ Day/Time: __________
Date: _______  Name: ____________  Relationship to Child: __________ Day/Time: __________
Date: _______  Name: ____________  Relationship to Child: __________ Day/Time: __________
Date: _______  Name: ____________  Relationship to Child: __________ Day/Time: __________

Name of Person Completing the Form:  ___________________________________________
Signature:__________________________________________________                        Date:_________________________________

Received by St. Clare’s (date):____________________________