Respite Interest Form - Integral Care

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Please fill out this form to the best of your ability for anyone you think may benefit from Respite. This form can take about 5 minutes to complete. Please note that Integral Care Staff will be in contact within 3 business days. This form will not allow earlier requests.

For Respite to be provided, the individual must meet the following requirements:

Must have an intellectual and/or developmental disability diagnosis
Be actively enrolled in Integral Care IDD Services
Resident of Travis County
Lives with family/caregiver in own home/family home
Age 4 and up
Respite Support Professionals are not able to provide medical care.

Please enter the date/time you want your appointment using the form below. We will contact you to confirm availability and to schedule. For individuals interested in accessing IDD Respite Services but are not enrolled in IDD Services, please contact our helpline 512-472-4357 to schedule an IDD Intake.

Respite Interest Form Submission(Required)

Are you the individual who will be receiving services?

Yes

Relationship to the Individual(Required)

Primary Caretaker/Family Member/Legal Guardian

Integral Care Staff

Outside Agency

Other

Fill out your information

Please fill out the form below. All fields are required except for the last additional information text box.

Your Name(Required)

First Last

Name of the individual who will be receiving services(Required)

First Last

Phone Number(Required)

Best contact number

Best email address to respond to regarding Respite interest form submission

Age of Individual(Required)

Please enter a number less than or equal to 120.

Preferred date that you would like Respite to be provided(Required)

Preferred start time you would like Respite to be provided(Required)

Preferred end time you would like Respite to be provided(Required)

Do you have any additional information you would like to provide in regards to this request?

(optional)

Peer Connection is an optional service designed to foster social engagement and community integration by matching our respite clients with peers for structured group activities while being supported by their respite support professional.(Required)

I’d like more information on Peer Connection Services.

Yes

This field is for validation purposes and should be left unchanged.