Behavioral Respite Inquiry


 Applicant Name:    

 Street Address:  

 City:     State:  ZIP:

 Home Phone:         Cell Phone:        E-Mail:

 Current Employer:         Languages Spoken:

 Have you ever worked for High Desert in the past?    
Yes  No
 Are you certified in CPR and First Aid?       
Yes  No
 Are you certified in any de-escalation training?                     
Yes  No
 Do you have a current drivers license?
Yes  No                              
 Do you have reliable transportation?
Yes  No                                  
 Do you have children of your own? 
Yes  No                             
 Do you have any pets?
Yes  No                                                         
 Do you smoke?
Yes  No                                                                               

 Where are you most interested in providing respite services?
Your home  Community  Client's home  
 Would you be interested in providing respite at any other location?
Yes  No  
 If so please indicate at what other locations

Any location  Your Home  Community Client's home

 What ages of youth are you interested in working with? (3-17)

 I am interested in working with 

 Please indicate below what days / hours you are available to care for a youth






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Copyright 2006 by High Desert Family Services, Inc. All rights reserved.
Revised: 07/23/17 13:07:27 -0600