Florida Respite Care for ALS Caregivers Application Please answer the following questions to confirm your eligibility for this program. 1. Does the person living with ALS live in Florida?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. 2. Does the primary caregiver reside in the same home as the person living with ALS?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. 3. Is the person with ALS eligible for service-connected, veteran's benefits?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. 4. Does the person with ALS have a long-term care insurance policy?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. 5. Does the person with ALS live in a skilled nursing facility?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. 6. Does the person living with ALS receive care through Florida's Statewide Medicaid Managed Care - Long Term Care Program?YesNo Thank you for taking time to answer the eligibility questions. We are sorry to share that due to program requirements, you are not eligible for this program. Please contact the ALS Association (als.org/support/states) in the state where the person with ALS resides for ALS-related information and resources. Person Living with ALS: First Name Last Name Street Address City State Zip Code County Email Address Phone Number Full-Time Caregiver: First Name Last Name Email Address Phone Number 1. Have you used respite services before?YesNo 2. If you receive grant funding for respite, do you plan to use an agency or do you plan to privately hire an individual?"Self-coordinated" - Families may choose to contract with an individual of their choice, other than a family member."Agency" - Families may select a home care agency to provide a professional caregiver. 3. If you received grant funding for respite, do you have an individual or agency in mind to hire? Yes, I have an individual/agency in mind to contact.No, I do not have someone in mind and would need assistance. 4. What needs or challenges have caused you to explore or use respite services? *Can select more than one answer.Inability or difficulty walking for the person living with ALSNeeding help transferring the person living with ALSThe person living with ALS has more difficulty with daily living activitiesExhaustion or feeling overwhelmed as a caregiverOther, please specify. Please specify the needs or challenges that have caused you to explore or use respite services. 5. How often do you hope/plan to use respite services?DailyWeeklyMonthlyOccasionally (Vacation, e.g., a long weekend) 6. What days and times do you have the greatest need for respite and hope to hire services?Weekdays - Daytime hoursWeekdays - Evening hoursWeekends - Daytime hoursWeekends - Evening hoursOvernightOther, please specify. Please specify what days and times you have the greatest need for respite and hope to hire services. 7. How do you hope to spend the time you have with respite support? *Can select more than one answer.Go to a social gathering like lunch or a movieTake a walk or enjoy some form of activityRest or take a napGet a haircut or some other form of self-careAttend a caregiver support groupOther, please specify. Please specify how you hope to spend the time you have with respite support. The following series of questions will not impact your eligibility or selection for this grant. This information will be helpful as the ALS Association seeks other funding opportunities to expand the respite program. 1. Please describe your financial situation. Please help us understand your need for financial assistance for respite. 2. What is your total monthly income? 3. What are your total monthly household expenses? Applicant Agreements: 1. By selecting "I agree." and submitting this document, I understand that this program is designed to provide financial support and resources to assist families affected by ALS in accessing respite services. The ALS Association assumes no responsibility to assist families affected by ALS in accessing respite services. The ALS Association assumes no responsibility or liability for any direct or indirect services, products, or client care, or for the care arrangement and/or business relationship between the client and their selected product or service provider.I agree. 2. By selecting "I agree." and submitting this document, I understand that completing this application does not guarantee approval for a grant or funding.I agree. 3. By selecting "I agree." and submitting this document, I understand and agree to the following statements as terms of the grant program:o This grant program is designed to provide respite to full-time caregivers who live in the same household as the person living with ALS. o Paid respite caregivers may not be family members. o Awardees are required to participate in a 45-minute orientation (will be available recorded) about the program and helpful tips in hiring respite services. o Funds should be utilized within six months of award grant receipt. o Awardees are asked to complete two surveys (three-month and six-month point) to provide feedback on accessing respite services. Your feedback will be helpful as we look to expand respite programming for families affected by ALS. o Awardees are asked to submit receipts for respite services at the end of the six-month award period.I agree. Contact Information
