State of Wyoming

State of Wyoming Behavioral Health Division

State Respite Program

Information & Application Dear Parent(s):

I would like to take this opportunity to share some information with you about the State of Wyoming Respite Program. This program is offered by the Behavioral Health Division to provide respite for a child who meets the qualifications as listed below.

Using the State of Wyoming Respite Program does not interfere with your child’s status while waiting for waiver funding on the Medicaid Children’s DD Home and Community Based Waiver or Supports Waiver.

The State Respite program may not be used if a child is already on a Medicaid Waiver program.

In order to meet the qualifications for the program your child must be under the age of 21 and have a developmental disability. A developmental disability is defined as a severe, chronic disability which is attributable to a mental, emotional or physical impairment or a combination of impairments that is likely to continue indefinitely and results in substantial functional limitations in three (3) or more of the following areas:

1. Self Care 2. Receptive and expressive language 3. Learning 4. Mobility 5. Self-direction 6. Capacity for independent living 7. Economic self-sufficiency

We recognize how important it is for parents to be able to take a break from the care of their child (respite), for a couple hours. It is important that the people taking care of your child provide for their safety. Individuals who want to care for State Respite children must go through an extensive background check to help ensure the child’s safety.

Because it is often expensive to find someone to care for children with disabilities, the base rate for respite providers is $8.00 an hour. There is a co-payment system based on parental income.

If you would like to be considered for State Respite services, please complete and return the enclosed application with supporting documentation. An outline explaining what you need to do is attached.

We hope you find this program helpful to your family. If you have any questions, please call me at (307) 777-7684.

Sincerely,

Linda Trujillo State Respite Coordinator Parent Application Process

. Use the enclosed tracking page to gather the needed information and return all information, as a single packet, to the Behavioral Health Division.

. The State Respite Coordinator will review your application to determine eligibility. You will be informed of the eligibility decision within 30 days of receiving your completed application and supporting documentation. Do not begin respite services until you have received official notification that your child qualifies for the program.

. If your application is approved, you will be informed of your co-payment amount as well as the number of respite hours available to your child per month.

. There may be approved respite providers in your area for you to choose from. If not, we encourage you to identify a person whom you want to become your respite provider. She/he must complete a Provider Application, and go through background checks. The background checks can take a couple of months to complete. If you have identified a prospective respite provider, please have them contact the State Respite Coordinator as soon as possible to obtain a Provider Application.

. Once you have chosen an approved provider, it is your responsibility to train that person in the care and needs for you child. You must sign the Statement Confirming Qualifications form and return it to the Behavioral Health Division.

. If you are having troubles finding a State Respite Provider contact the State Respite Coordinator at (307) 777-7684 to get a list of approved providers in your area.

. You must maintain a record of the hours of respite provided for your child.

. Each quarter, you will be receiving notification of the respite hours available for your child per month. It is your responsibility to contact the State Respite Coordinator should you change your address or phone number.

Please return all forms to:

Behavioral Health Division Attn: State Respite Coordinator- Linda Trujillo 6101 Yellowstone Road Ste 259A, Centurylink Building Cheyenne, WY 82002

Or email: [email protected] TRACKING PAGE STATE OF WYOMING RESPITE PROGRAM- PARENT APPLICATION

Dear Parents:

The following items are required to enroll your child in the State of Wyoming Respite Program. Please complete and gather all information and send it to the Division as a single packet. In this way, your application can be reviewed and a decision about eligibility can be made with fewer delays. Send copies of medical or assessment information, not the originals. Keep a copy of all items you send in for your own records. I would encourage you to use this form to gather your information and then date it when you have sent the entire packet to the Behavioral Health Division.

______Completed Application

______Medical information with your child’s diagnosis; or

______Psychological report and/or assessments done by Physical, Occupational or Speech Therapist or Multidisciplinary Team Review.

______Statement Confirming Qualifications of Respite Provider

______Most recent tax return or verification of income.

Child’s Name ______

Parent’s Name______

Date sent by parent ______

Behavioral Health Division Linda Trujillo, State Respite Coordinator 6101 Yellowstone Road Ste 259A, Centurylink Building Cheyenne, WY 82002 (307) 777-7684 | Fax: (307) 777-6047 [email protected] WYOMING DEPARTMENT OF HEALTH BEHAVIORAL HEALTH DIVISION STATE OF WYOMING RESPITE APPLICATION

Child’s Name: ______Last First Middle

Child’s Social Security Number: ______-______-______

Birth Date: ______/______/______Sex: M or F

Parent / Guardian’s Name: ______(Please circle one) Current Address: ______Street City Zip

Phone (_____) ______-______(______) ______-______Home Work

Number of individuals in your family: ______

Calculate Income below: Adjusted Gross Income from most recent Income Tax Form: ______

Yearly Medical Deductions: ______(Example: out-of-pocket medical expenses for the child-include health insurance premiums) If claiming please send a copy of one of the following: IRS 1040 forms, hospital & doctor’s statements, copies of loan or payment agreements or evidence of on-going monthly costs.

Adjusted Gross Income minus Yearly Medical Deductions______

What is your Child’s Disability? ______Please attach a diagnosis from your doctor and a copy of the assessments used for your child’s IEP or IFSP from the school.

Is your child(ren) on the Children’s Home & Community Based Waiver? Y or N Is your family receiving other respite services? Y or N If yes, how many hours are you receiving? ______Who is the provider? ______

I certify, under penalty of perjury, all information I have given on this application is true to the best of my knowledge. I understand that the Developmental Disabilities Division will not be responsible for the actions of the provider.

Please return to: ______Behavioral Health Division Parent or Guardian Signature State Respite Coordinator: Linda Trujillo 6101 Yellowstone Ste 259A ______Cheyenne, WY 82002 Date Phone: (307) 777-7684 FAX: (307) 777-6047

*Parents may be expected to pay part of the $8.00 per hour fee based upon yearly income provided above. Revised 11/02

STATE OF WYOMING RESPITE PROGRAM

PARENT CO-PAYMENT SCHEDULE

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Parent’s $.00 per $.25 per $.50 per $.75 per $1.25 per $1.75 per $2.50 per Co-pay hour hour hour hour hour hour hour Family Adjusted Gross Monthly Income of Parent(s) Size 1 0-414 415-568 569-710 711-852 853-994 995-1136 1137+ 2 0-585 586-766 767-958 959-1149 1150-1341 1342-1552 1553+ 3 0-674 675-964 965-1205 1206-1446 1447-1687 1688-1928 1929+ 4 0-753 754-1163 1164-1454 1455-1745 1746-2035 2036-2326 2327+ 5 0-908 909-1361 1362-1702 1703-2042 2043-2382 2383-2722 2723+ 6 0-996 997-1559 1560-1949 1950-2339 2340-2728 2729-3118 3119+ 7 0-1144 1145-1758 1759-2198 2199-2637 2638-3077 3078-3516 3517+ 8 0-1226 1227-1956 1957-2445 2446-2934 2935-3423 3424-3912 3913+ add add add add add add add 8+ $100/person $150/person $200/person $250/person $300/person $350/person $400/person STATE OF WYOMING RESPITE PROGRAM

STATEMENT CONFIRMING CHOICE AND QUALIFICATIONS OF RESPITE PROVIDER

______I, ______have chosen______(Parent / Guardian Name) (Provider Name)

To be the respite provider under the State of Wyoming Respite Program for:

______(Child’s Name). This person is an enrolled State of Wyoming

Respite provider. I verify that this person is knowledgeable about the special needs and care of my child and I will keep the provider updated with any changes.

______Parent/Guardian Signature

______Date

______I have not chosen a respite provider and would like to have a list of approved providers in my area for the State of Wyoming Respite Program in order to make a choice. Once I have chosen, I will notify the Behavioral Health Division of my choice and will train the provider in the special needs and care of my child.

______Parent/Guardian Signature

______Date

Mail, Fax, or scan and email to: Behavioral Health Division Attn: Linda Trujillo, State Respite Coordinator 6101 Yellowstone Road, Ste 259A Cheyenne, WY 82002 Fax: (307) 777-6047 | [email protected]