Respite Intake Form

Due to the spread of the COVID-19 virus, we are only allowing medically essential people in our buildings. Also, do not enter the building if you have cold or flu symptoms. We apologize for any inconvenience, but we would like to protect the medically fragile population we serve. If you have questions or are attempting to make a delivery, please contact Human Resources at 719 574-5562, extension 239 in Colorado Springs, Juanita Macias at 719 574-5562, extension 226 in Pueblo.

Respite Intake Form

Basic (Client Information)

Demographics

Medical Information

Medicaid

Admissions & Status

Family and Friends