Maintaining Connections: Nurturing Relationships and Marriage While Caregiving

Maintaining Connections: Nurturing Relationships and Marriage While Caregiving

Sunday, November 23rd 3-5 PM
Caregiver Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Would you like respite services for your participant?*

YesNo

Gender of participant*

FemaleMale
Name of Participant*

First NameLast Name
Disability of Participant:*
Age of Participant*
Do they have some kind of supportive device? If so, what is it? *
What is their best mode of communication?*
What do they find challenging? *
What are the challenging behaviors we are likely to see when they are upset?*
How should one calm a negative behavior?*
List any dietary restrictions for them? Do they have any allergies? Any food sensitivities/texture sensitivities*
List any applicable information for toileting*
What are their preferred activities?*
What are some strengths of theirs that we can build on?*
Is there any additional information you would like to share?*
My Products
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Respite Ticket
Please purchase one ticket per participant

$5.00 Quantity
Item subtotal:$0.00

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.