Referrals Page

The first 3 forms are used by families to apply for our Respite Services:

1.   Family Preferences Form: English      Spanish
2.   Matching Staff Worksheet:   English     Spanish
3.   Designated Respite Worker Waiver: English   Spanish
(This is used if the family will be referring someone to be hired)

These simple forms assist us in getting to know your family's needs better and helping you find
someone to give you some respite! If you have trouble viewing or printing them, call us and we can mail
them to you.

This form is used for families to authorize their Respite Caregiver (over age 21) to transport their child to
local activities: Travel Authorization Form: English    Spanish

* Service Coordinator Info. *

1. Service Coordinator and Family decide on agency respite services and do an IPP amendment

2. Selected In-Home Respite Agency (Channel Islands) receives confirmation of approved Electronic
authorization for services by email from the SC to Edith@IslandSocialServices.org with Sandis Face
Sheet and copy of IPP/amendment (or fax to 805-299-0600).

3. Agency calls family (and their preferred Respite Caregiver if known). Packets are sent out for
completion by both family and Respite Caregiver, then returned to agency for processing. If no caregiver
is referred by family, agency recruits caregiver, then has them meet family/child for at least an hour to
ensure good match.

4. Respite Caregiver passes initial screening, is trained and hired. Family is notified that Caregiver is
hired and when services may begin.

5. Family calls Respite Caregiver(s) directly to schedule their respite needs each month.

REFERRAL PROCESS
* Family Application Forms *