2025-2026 Respite Application Packet

About the Alabama Lifespan Respite Reimbursement Program
What is Respite? A temporary short break to give relief to family caregivers from the extraordinary intensive demands of providing ongoing care in the home for a loved one with special needs.

Who is a Primary Caregiver? A person who provides full-time (40 or more hours per week) unpaid care to assist with activities of daily living (bathing, dressing, feeding, medication management, errands, chores, etc.) for a parent, spouse/partner, child, sibling, grandparent, or other family member who requires full-time care due to a disability or chronic illness.

Who is a Care Recipient? A family member who requires full-time care due to a disability or chronic illness (proof of diagnosis required).

Who is a Respite Provider? A person hired by the Primary Caregiver to give them a short break (respite) from daily caregiving duties. Respite provision at onsite, fee-based respite day/evening
programs and camps are also eligible for reimbursement. What is Respite Reimbursement? Alabama Lifespan Respite does not employ Respite Providers. Therefore, Caregivers are responsible for identifying, hiring, and training Respite Providers (or enrolling their Care Recipient in a day/evening program or camp) to receive respite and will be reimbursed for services rendered based on timesheet guidelines. Reimbursement is not income and should not affect SSI benefits.

What are Timesheets? Timesheets are simply a paper form that documents when and how long respite took place and who provided the respite (Respite Provider).

How the program works: Once a Caregiver applies and is qualified for the respite reimbursement program, the Caregiver will receive a welcome packet with instructions and atimesheet indicating the amount of reimbursement award they will receive for a specific period of time. Caregivers may choose anyone they wish to provide respite and may require training (such as
CPR or basic First Aid), if they so choose, but the level of training is at the discretion of the Caregiver. The Respite Provider must be at least age 18 and may not live in the same home as
the Care Recipient. More than one Respite Provider may provide respite during the dates listed on the timesheet and be recorded as such. Caregivers/Respite Providers mutually determine a
rate of pay. When respite service is completed, the Respite Provider signs the timesheet to confirm the date and time respite was received. The Caregiver will pay the Respite Provider out-of-pocket and submit the completed/signed timesheet to Alabama Lifespan Respite, who will issue a check to reimburse the Caregiver (based on award amount that must be utilized during the specified time
frame). Once Alabama Lifespan Respite receives the completed/signed timesheet and verifies information, reimbursement will be issued to the Caregiver within 30 days.

STOP! Please read the following information fully before completing your application.
Sign and return this page with your competed application.

Are you a full-time, unpaid, family caregiver for a loved one of any age with a chronic illness or disability that requires around-the-clock care? Do you need a break (also known as respite)? If so, you are invited to *apply for the Alabama Lifespan Respite Reimbursement program.

*If you have applied for and received respite reimbursement from Alabama Lifespan Respite after July 1, 2025, there is no need to reapply. Re-enrollment information will be sent to
recipients annually. NOTICE: The completion of this application does not guarantee the awarding of financial assistance from Alabama Lifespan Respite. Please note that while Alabama Lifespan Respite wishes we could help all qualified individuals who seek assistance, regrettably we only have limited funds to meet the needs of qualified caregivers. Therefore, we can only respond to
requests based on our available resources.

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Please mark that you have read and understand each of the following guidelines before applying for the Alabama Lifespan Respite Reimbursement Program. *

• I understand that I cannot currently be receiving respite services through any other program in order to qualify for the Alabama Lifespan Respite reimbursement program
• I understand that only one caregiver per household is eligible to apply.
• I understand that only one individual per household may be listed as the care recipient. (If you are caring for multiple individuals with special needs, please only list the individual who requires the most care.)
• I understand that I cannot be listed as both the Primary Caregiver and the Respite Provider, and that the intent of this program is to reimburse me after I have paid a third-party for respite.
• I understand that I must submit a proof of diagnosis for my care recipient, which is required to process my application.
• I understand that I am responsible for selecting and training a trustworthy respite provider(s) who is at least 18 years of age and who lives outside of the care recipient’s home. Neither Alabama Lifespan Respite nor UCP Huntsville will be held responsible for any actions taken by my selected respite provider.
• I understand there is a 30 day processing period before I will receive reimbursement in the form of a check. If I cannot wait 30 days for reimbursement, I understand that this program does not fit my needs and I will not apply to the program.
• I agree to use respite reimbursement funds only for respite care.
• I understand both the caregiver and care recipient must be residents of Alabama

Signature *

Clear Signature

Date *

Alabama Respite Application

Primary Caregiver:

(This name must be used consistently on all documentation for this program moving forward.)

Last Name: *

First Name, MI: *

Caregiver Mailing Address *

City *

State *

Zip *

County: *

Caregiver DOB: *

Caregiver Gender: *

• Female
• Male
• Other

Preferred Method of Contact: *

• Email
• Postal Mail

Email Address: *

Phone number with area code: *

Is your gross monthly income above $1,500? *

• Yes
• No

1. How are you (Primary Caregiver) related to the Care Recipient? I am their… *

• Parent
• Spouse or partner
• Child
• Court Appointed Legal Guardian
• Sibling
• Grandparent
• Other

Please describe *

2. Please specify military status: *

• Served
• Never served

Active or Retired *

• Active
• Retired

3. Please select your race: *

• Asian or Asian American
• Biracial or Multiracial
• Black or African American
• Native Hawaiian or Pacific Islander
• White
• Other

Please describe *

4. Please identify your ethnicity. *

• Hispanic or Latino
• Not Hispanic or Latino

5. Do you (Primary Caregiver) and the Care Recipient live in the same household? *

• Yes
• No

6. How many hours of care do you provide in a week (please estimate)? *

• Less than 40 hours
• Between 40-60 hours
• Between 60-80 hours
• 80+ hours

7. Are you interested in receiving information about free caregiver mental health counseling, education, and supports? *

• Yes
• No

8. On a scale of 1 to 10 (1 being little to no stress and 10 being very stressed), please determine your stress level at this time. *

. Please check any respite services you are currently receiving from the list below. If you are currently on a waiting list for any services below, please record the date you applied. If none, proceed to the next question.

Medicaid Waiver Home Based Services

• Medicaid Waiver Home Based Services (respite only, not health insurance)

Alabama Cares

• Alabama Cares

HEARTS

• HEARTS

Alabama Head Injury Foundation

• Alabama Head Injury Foundation

Date:

Date:

Date:

Date:

Veteran’s Administration (Aid and Attendance)

• Veteran’s Administration (Aid and Attendance)

Autism Society of AL

• Autism Society of AL

ALS

• ALS

Other

• Other

Date:

Date:

Date:

Name of Program

Date:

10. ¿Prefieres recibir información en inglés o español?

• Español
• Inglesa

Care Recipient Information

no Respite Medicaid

Last Name: *

First Name, MI.: *

Date of Birth *

Gender: *

• Female
• Male
• Other

Race: *

Primary Diagnosis: *

Attach Proof of Diagnoses *

Drag & Drop Files, Choose Files to Upload

Primary Caregiver Signature: *

Clear Signature

Your typed name may serve as your signature and confirmation that all above information is correct:

Date: *

Submit