Please note that this is a two step application. Applications will not be accepted and reviewed until both steps are completed.
We are currently accepting applications from patients who reside in the following counties: Adams, Berks, Bucks, Chester, Cumberland, Delaware, Dauphin, Lancaster, Lebanon, Montgomery, Perry, Philadelphia, and York. If you do not live in one of these counties, please check back regularly as our goal is to continue to expand our reach.
Complete by Patient (Parent/Guardian)
Please begin by completing this application form. You will be asked to provide some information about the patient and the individuals who will be attending the respite. We will ask for some details surrounding your preferences for the respite, including time and destination. We will also ask about the situation surrounding the patient's illness, and why a respite is needed.
Complete by Medical Professional
Please reach out to your medical team to complete the following portion of the application. Acceptable members of one's medical team include, but are not limited to: physicians, nurse navigators, primary care physicians, social workers, nurse practitioners, etc. If they have questions when filling out the application, have them refer to our FAQs, or contact us directly at email@example.com