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In order to participate in Respite Night at The Hive, participants or their guardians must submit the following intake form. Our staff will review your information and reach out with Respite Night availability. This form is for individuals participating through scholarship or private pay. For information on billing an HCBS waiver, please reach out to us directly.

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Short-Term Respite Intake & Safety Form (Non-HCBS)

  1. Participant Information

Date of Birth
Month
Day
Year

  1. Emergency & Guardian Contact

Guardian reachable during program?
Yes
No

  1. Health & Safety

Note: No medications will be administered during this program.

  1. Supervision & Personal Care

Level of supervision needed:
Independent
Intermittent
Close

  1. Support & Behavior Information

  1. Consent & Acknowledgment

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