OKDHS Respite Voucher Application

State seal

OKLAHOMA DEPARTMENT   OF HUMAN SERVICES

Developmental Disabilities Services   Division

Respite Voucher Application

OKDHS

Download – Respite Voucher Application 01-28-13

Section 1. Care   Recipient Information:  (The child or adult with a developmental   disability or developmental delay to whom care is provided)
Last   Name

 

First Middle Date   of Birth
Age

 

Race Gender Social   Security #
Street   Address

 

City
County State Zip   Code

 

Marital   Status
Does   the child or adult have a special/chronic health care need?

Yes     No  Age Diagnosed ______

 

Does the child or   adult have a developmental disability or developmental delay?

Yes   No  Age Diagnosed ______

 

Diagnoses:_____________________________________________________________________

______________________________________________________________________________

 

Receives   SSI?

Yes     No

Receives   SSA?

Yes    No

Child   adopted through OKDHS?

Yes     No

 

In   OKDHS Custody?

Yes     No

Lives   in an Assisted Living Facility?

Yes     No

Lives   independently?

Yes     No

 

Resides   in a drug or alcohol treatment facility?

Yes     No

 

Receives   services through the Advantage Waiver?

Yes     No

Receives   services through a Home and Community-Based Services Waiver?

Yes     No

Receives   state funded Sheltered Workshop Services?

Yes     No

Hours   per week _______________

 

Receives   state funded Community Integrated Employment Services?

Yes     No

Hours   per week ____________________

Receives   state funded Adult Day Program Services?

Yes     No

Hours   per week

_____________________

Receives   any other state funded service(s) through DDSD?

Yes     No

Hours   per week ___________________

 

     
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