STOP If you have not been directed to fill out this form by The Homeless Project, please first contact Duane Mellor at 954-600-1506 Please enable JavaScript in your browser to complete this form.Case Manager/Requestor *FirstLastDate *Phone Assessment Completed and Approved by Duane Mellor or Veronica Figueroa prior to form completion? *YesNoThis preapproval is mandatory in order to proceed with the request.Date Completed *Identify Respite Staff Member *FirstLastPlease type the name of the aproving Respite Staff Member.Number of Days Requested *Expected Admission Date to Respite *Case Manager/Requestor Phone *Case Manager/Requestor Email *Supervisor Name *FirstLastSupervisor Phone *Supervisor Email *Provider Name *Section A: Demographic InformationPerson Served *FirstLastDOB *Gender *MaleFemaleOtherSSN *Race *BlackWhiteNative American/Alaskan NativeNative Hawaiian/Pacific IslanderAsianMulti RacialEthnicity *African AmericanHispanic/LatinoJamaicanHaitianOtherPreferred Language *EnglishSpanishCreoleOtherBenefits Status *Currently ActiveInnactiveNo BenefitsOtherExplanation *Benefits Amount $ *Criminal Status *Primary Income Source *SalaryDisabilityTANFRetirement/Pension/SSINoneUnknownOtherEmployment *Active Military, OverseasTerminated/UnemployedActive Military, USAHomemaker (must keep house for 1 or mother others)Full TimeStudentUnpaid Family WorkerDisabledPart TimeCriminal InmateLeave of AbsenceInmate OtherRetiredNot Authorized to WorkHighest Level of Education Completed *Primary SchoolHigh SchoolAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorate/PhDVocational TrainingSection B: Request DetailMental Health DiagnosisYesNoPrimary ICD-10 *Secondary ICD-10 Substance Use DisorderMedications (current) *Client's Discharge Plan (After Respite) *Discharge Plan Supporting Documentation *RTF, ALF, AFCHFriend/Family VerificationOtherUpload Documentation Click or drag a file to this area to upload. Submit