Dear Parent or Legal Guardian:
Thank you for your interest in NAMI Maine’s Respite Services Program. This program is funded by the
Department of Health & Human Services (DHHS) and is designed to give families of children with special
needs planned breaks. Upon completion of the application process, your family may be allotted up to 16 hours
per month for planned respite service, as long as funding remains available.
Enclosed in this application packet are the necessary forms to be completed to apply for respite services. Some
of the enclosed forms must be completed for each child for whom you are applying for services. Please make
sure all original forms are completed and returned to ensure a speedy process. Please send the original
documents – not photocopies.
Before you mail original forms to us, please use the following checklist to make sure you have included
everything that is required.
Family Application includes: Respite Care Services Application, Determination of Fee Form,
Parental Responsibility, Notification of Consumer Rights, Authorization to Release Information
and Family Report Form (completed & signed by parents/legal guardian)
Child Application Section (separate form for each child being served)
Respite Service Use Form (complete & return)
Please also include this important documentation:
Proof of Legal Guardianship (only needed if you are not the biological parent)
Documentation of Diagnosis (diagnosis documentation must include a full evaluation, less than
three years old, by a licensed professional. Notes from a doctor, or case management intake
summaries are not accepted.
Thank you for your inquiry. If you have further questions, please feel free to call NAMI Maine or email us at
Carol Carothers, LCPC, LADC