Empower Simcoe | Family Relief Information Update

Child's Name

First

Last

File #

Age

Gender

Please Specify

Parent/Guardian Name

First

Last

Parent/Guardian Email

Preferred Method of Contact

Can we leave a message?

ACSD (Assistance for Children with Severe Disabilities)

Yearly or Monthly Amount Received by ACSD

SSAH (Special Services At Home)

Yearly or Monthly Amount Received by SSAH

OAP (Ontario Autism Program)

Yearly or Monthly Amount Received by OAP

Recreational Funding (Health Star, Jump Start, etc.)

Yearly or Monthly Amount Received by Recreational Funding

Other Funding

Name of Other Funding

Yearly or Monthly Amount Received by Other Funding

Please indicate how you intend to use respite funding should it be renewed.

Please select all the options that suit your family's respite plan.

Please describe 'other' respite service

Estimated total cost of respite ($ per year)

Do you currently have a Respite Worker or Mediator?

Are you familiar with supportyourway.ca that assists with connecting to respite providers in your area?

Have there been any changes over the past year that directly affect your respite needs?

Please Explain

Have your respite expenses changed?

Please choose which priority level best describes your need for Family Relief Funding

Is there any additional information you would like to update or share with us regarding your need for respite funding?

I give consent to have the information from this document shared with the Family Relief Allocation Committee

Person completing this document