Add Your Program

Each local respite provider must be registered separately. Agencies with multiple listings must use a different User Name (below) for each listing.

Please NOTE that the information you enter into this form will not appear immediately on the web. The web pages are submitted for approval by administrator at a later date. We update all the pages on regular basis. Our automated emailing system will send you an email as soon as your program has been added. Thanks for your patience!

1. Please Provide the following contact information: *Required field
*Username
*Password
*Confirm Password
*Status
 If your agency is already listed on the Respite Locator Service, please select the Current Listing option in the Status box.
*Organization
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
Country
*Office Phone
Hotline Phone
Fax
*E-mail
URL
 

2. City and County names in service area

3. Check all the locations in which services are offered
Free Standing Respite Facility
In-home program (services occur in consumer's home) Foster Care Home
Child Care Center Hospice
Senior Center Community Center
Provider's Home Adult Day Care
Hospital Skilled Nursing Facility
Crisis Shelter Nursing Home
Respitality Family Center
Residential Facility Faith-based Center (e.g., church, synagogue, temple, mosque)
Camp Assisted Living Facility
Other setting:

4. Services:
 
Yes
No
  
Do you offer emergency service?
 
Do you offer Crisis Nursery service?
 
Do you offer Elder Crisis service?
 
Weekend or Overnight Respite?
 
Up to what length of time?

5.Will serve clients with the following disabilities:

AIDS/HIV Attention Deficit Disorder
Autism Developmental Disabilities
Spinal Cord Injury Neurological Conditions (e.g. ALS, MS)
Emotional or Mental Health Conditions Epilepsy
Hearing Impairment History of Abuse/Neglect
Intellectual/Cogntive Impairment Medically Fragile Conditions
Physical Disabilities Potential Abuse/Neglect
Visual Impairments Speech/Language Disorders
Chronic Illness/stroke Frail Elderly
Alzheimer's/dementia Brain Injury
Other Disability:

Payment System: Sliding Scale    Vouchers     No Charge   
Private Insurance Medicare          Medicaid    Self Pay
National Family Caregiver Support

Other State or Federal Gov’t Funding: please describe

Age range of clients you will serve:
From age to age

Office hours


When you hit the "Submit" button, there may be a delay of up to 60 seconds before the page acknowledging your submission appears. Please be patient and don't submit your information more than once. Thanks for your help.