ࡱ                >  	                                          3 	                  bjbj΃                  	                                                                      l     J      J  J      J      J      J      J             ^      8      8      8  8   p  <        ^        8  |                            Y    -    9     S     U      U      U      U      U      U      0      P"  v   U  ]                   J                            7  "   Y                  U            J      J                      )                           
   J            J            S                                                                          S                         _      J      J                                                              _            p     @Q^    8            _              _      0         _      "            "      _            ^      ^      J      J      J      J                                   Family Referral FormReferral from  FORMCHECKBOX  DCYF FORMCHECKBOX  BDS FORMCHECKBOX  BEAS FORMCHECKBOX  Other State Agency FORMCHECKBOX ______________Name of person who made the Referral FORMTEXT                                                                                                                                                                                                                                                                         D a t e   o f   R e f e r r a l     F O R M T E X T            P h o n e   o f   C o n t a c t   P e r s o n     F O R M T E X T               F a m i l y   i s     F O R M C H E C K B O X       A d o p t i v e       F O R M C H E C K B O X       R e u n i f i c a t i o n     F O R M C H E C K B O X     F o s t e r     F O R M C H E C K B O X       P r e v e n t i v e   C a r e     F a m i l y   C o n t a c t   N a m e     F O R M T E X T               N a m e   o f   C h i l d   t o   R e c e i v e   R e s p i t e   S e r v i c e s     F O R M T E X T               F a m i l y   C o n t a c t   M e t h o d     F O R M C H E C K B O X       P h o n e     F O R M T E X T               F O R M C H E C K B O X     E m a i l       F O R M T E X T                  P r o v i d e r   R e q u e s t e d     F O R M C H E C K B O X       Y e s        F O R M C H E C K B O X     N o  D a t e   t o   S t a r t     F O R M T E X T               A d d i t i o n a l   C o m m e n t s     F O R M T E X T                  F O R M T E X T               F a m i l i e s   R e s p i t e   N e e d s   / C o n c e r n s :     F O R M T E X T                  F O R M T E X T                  F O R M C H E C K B O X         I n   c h e c k i n g   t h i s   b o x   ,   t h e     p e r s o n   l i s t e d   a s   m a k i n g   t h e  referral  , verifies there is documented evidence to support the named child ,who will receive respite care through the Lifespan Respite Grant /SMS, has been diagnosed with SED ( severe emotional disturbance)   This area is for Lifespan Respite use onlyFamily /Provider Link  FORMTEXT                                                                                                                                                                                                                                    D a t e   L i n k   M a d e     F O R M T E X T               F O R M C H E C K B O X     B y   E m a i l     F O R M C H E C K B O X       B y   P h o n e      L i n k   M a d e   b y     F O R M T E X T              S u r v e y   C o m p l e t e d  H o u r s   U s e d   f o r   R e s p i t e  D a t e   o f   S e r v i c e  I n v o i c e   R e t u r n e d  S u b m i t t e d   f o r   p a y m e n t      F O R M C H E C K B O X       P r o v ider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family FORMCHECKBOX  Provider   FORMCHECKBOX Family                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                /  A  B  P  Q  R  X  Y  g  h  i  n  o  }  ~                                      
      6  8  L  N  P  Z  \  ^     t   j  OJ  QJ  Uj    OJ  QJ  UmH nH u jD  OJ  QJ  Uj    OJ  QJ  UOJ  QJ   j  OJ QJ Uj\  OJ QJ Uj   OJ QJ Ujt   OJ QJ Uj    OJ QJ Uj    OJ QJ UOJ QJ  j    CJ UmH nH u-   /  0  1  2  A  X  n                                                                                                                                                                                                                                                                                                                                                                                                                                              $If         $a$  $ a$  
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 n           h            h            h            h                                                                                                                                     $If      $$If    T l ֈ 
 &                                   8                                  	                 `	                                                                                          4 
l a                                                  ;                                                     D  $$If    T l 0 x&                  p                                        4 
l a   	! $If     $If    l  $$If    T l  \ &                                    
                                                                                   4 
l a       6  ^          H                                                          E                                       j  $$If    T l \ h&                                 P
                                                                                 4 
l a   	! $If    
 ! $If     $If    1  $$If    T l  & T'                              4 
l a                               
  &  (  *  H  J  f  h  j  x  z                         l  n                ѼѰѤјрq  j    OJ QJ UmH nH u j  OJ QJ Ujp  OJ  QJ  Uj  OJ QJ Uj  OJ QJ Uj  OJ QJ Uj  OJ QJ Uj    OJ QJ UOJ QJ  j    OJ  QJ  UmH nH u j,  OJ  QJ  UOJ  QJ   j    OJ  QJ  U ,        H  x                                                                              H                            }  $$If    T l r (&                                                                                                                                                   4 
l a    $If   3  $$If    T l 4 & T'                              4 
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 ! $If    1  $$If    T l  & T'                            4 
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      4  6  J  L  N  X  Z  \  ^  z  |  ~                                                 #  $  2  3  4  ?  @  N  ޽ޱޙލށ                        j  OJ QJ Uj  OJ QJ Uj&  OJ QJ Uj  OJ  QJ  Uj:  OJ QJ Uj  OJ QJ Uj    OJ QJ UjN  OJ  QJ  UOJ QJ  OJ  QJ   j    OJ  QJ  Uj    OJ  QJ  UmH nH u.          4  \                                         od                      d                                                                                                 
 ! $If    D  $$If    T l 0 	& D
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l a              !  3           -            -            -            -               $If     $$If    T l             r P
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                                                                                    	
     2                              0                                6                                                                4 
l a !  "  #  W  X  Y  Z  [  \                P                                                                       P                             $$If    T l             r P
HX `' 
                                                                                    0                                6                                                              4 
l a  $If    	N  O  P  \  ]  k  l  m  x  y                                                          #  $  2  3  4  @  A  O  P  Q  y   j  OJ QJ Uj8  OJ QJ Uj  OJ QJ UjL  OJ QJ Uj  OJ QJ Uj`  OJ QJ Uj  OJ QJ Ujt  OJ QJ Uj  OJ QJ UOJ QJ  j    OJ QJ Uj  OJ QJ U /                                                                    P                                                                 $$If    T l             r P
HX `' 
                                                                                    0                                6                                                              4 
l a  $If    	                  ;              P                                                                       P                             $$If    T l             r P
HX `' 
                                                                                    0                                6                                                              4 
l a  $If    	;  <  =  >  ?  @  t  u  v  w                                                  P                                                                 $$If    T l             r P
HX `' 
                                                                                    0                                6                                                              4 
l a  $If    	Q  \  ]  k  l  m  y  z                                                                                                                                                                                                                                                                                                                                                          j  OJ QJ Uj  OJ QJ Uj$  OJ QJ Uj    OJ QJ UOJ QJ w  x  y                          P                                                                       P                                   $$If    T l             r P
HX `' 
                                                                                    0                                6                                                              4 
l a  $If                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         1h/ =!"#$%  F  ZP- JFIF      Exif  II*           C  C )"            	
    } !1AQa"q2#BR$3br	
%&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz        	
   w !1AQaq"2B	#3Rbr
$4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz   ? ( ( ( (rA>h#rGP9? Bx'iu;G q9O8<ZJ?m"j>I]+;W2[ɥo{qS.}.NEըѩ[Hh\gU鹵*5jߓDyk}< Ny<cn8'h~&7D{ k2bh>[Py q%e D]{e
u1WmC|^b˻|	&Ko#X/φWOxC6#quxZ>q;nۻVWO1.6պwѭNaiUsZ+;쯭կk?sɇo("jZe/e~xb-ѼFN
<]HiV' k ώQnYD;<cu5Xr(R6ŀ	4LGڰ;ct  x'?νqϯ
xJ)i=?>W}||^||u|a4wVUּ!]gӾZxFWvn
|;RVO	f'yIXsODԖz7i(<[,'gkfقKϦ `C%OI2O&O~m]J/tK5}"r t`~S9c=J__=*WR_MkًbEilt>'+5p߉?4~ m#N?;A
@E>?iPƏM_/1sYzGi٤o134dsׯED+}S֚骹?XwY/ڋb(>%||{Dq⯀5bT  ޵r~a9o-{X>ݽ_|FԼ>~hÚ.JZ#&VRnҴ#u=189'}GL}4i"g?imU4ۛMJ):eD(_YڤlVv5~Xu>lM_z\22#z׏ @.܇& d	py=Hk gb߳_LmMa,W~Ŗm7ڼ|JlD~߈|Oolt)<o_U/ƗKekWUw)|:V;H#7İhIm!oyЗ24gkVrJxI'M7m4mtUGsjR@('hqHG2SWqqcˊJe(5u^.&]  hQ@Q@Q@Q@Q@Q@Q@B&	\==p^מ*jN$@#1؜g<	٥KoOCw]5heAq<ODOj,񮿦wú^5;Hd,FKVK2eXWʾ4|q>>N_.k|4𸷽.'"hF#6hgAm''i?hn=7:<Qo麟ݼcɟ'\Դі cc
iRµMm~yp(>]SJ{M4s?_nhGg$R>7bf?H>7³^ķK&ҶҴ>QoM>m^y"\_Zw뺖jZ%ƥyz\]7L'W>Gu8%bO.'$o63XV*c`q`q YsJmF+^vw~zmk%R*vwNl]e
9?*P%p6`c'8zc*HJ~ v <W>o έ}([$[!QL)2=G(?SPosQ0I r9Z$_<|szM?
گigRd~izqGhEէ
²;%$輺wܺx|F&J4ue2<ۧ [' t
۱;A>Ǹ+_kSx?ZY<H|ƞ~^(еk>񅵾xZSkM3RD[#㇆g.=_Vb<Sm_C𿃼	A?|ix¾ʏSFU䯻^+ۮ
<`ܴvoG>Q2|W+
xk-]Nִ}Nk{;SӵD(o$m0F+ g_|.mu?xڞ{ZѬo *躙?mn>X P>UTr0矯hNziOG[ODgV-^TһI[.?gb~-YCTS]?׶Vm+"ikD_?h|\UT-40xǋм_$T_xx0ԅZ37[Eݼ{ 	 $~X~1~~yN_T!+izݞl-%uP|3<!8U"e}mgGQN֌MBs|4hs#Jw<b{|rT U9C>|s?Weoxf;%jܪLq<z7[;C}:E%ǁ@k[Ȯ*EC aOQ~URnWtMJzy5-a'x5}oӳO=QE QE QE QE QE S@<w<pW#~bm1ԽS]mzwwvBjr9l~Nrzuۀ|.MKNuCO|kw^2XkHd_u(u4ϋ4+{mB|ēQjF7?
>ix?il	ú|7Ő/f!]SX-[P/[I/@AŬ^M;%tӢfHd-F<=%RW*kdjz4ӡmWⵠmu- O;k)'-٢/mFZM=<#"3GK;"q Ibn 6@p2'xip\   C R7.0G@ҹUg/[mjU'9|;Eonݶ^?/Aʖ]Q@((eڄg} 3׸	:T-&vNק]vӣi5 b㏄_u/(Ρ|=|p" ^ލ[8VOkP[$R1`y'? w=Sk%|
mr_&GkZohW[o𗀼?qN R տ khk_~|:|EYxZ/ꉨDzid/^*=HF9A/	xWN?h^_Zi:}oy2%sM{y Vyn^etjQUړI.ߟ|=L<RrJ&׻~[_fOci ) 	k|5i?<;׾0h >3z>%5xZ׈y5?ƾJ, o >>+;_~-xSNeG]x?mi/w[I~$\AI>4"_ٵ
Up2cdB'v}qsdԓNI6i)I.eew6F\Wj륶K?fjj>׾-x~!pſ)|cQqHyzU/%oh6V0_4p<N|_	ϒ|Y@2h D mT8 0vώwɶ ﮏ{_6.KwקmWQqc Puqr;qMݬ~qmUׯ3⷇5K4}Gb&5n4kGԚ=֚Ν>ۈ&-j8P/~/~jռ;;å ytn&Sma4YxBh7Y/#|COd11 \c<)3σkkmŖ][2$ǲtbK䍄h(ս%dkKK?maQPķ읔]o K3[Ry$vOsW\8? x࿎tuxGWX[[oo]xѼ [_B#|m*V[rR@!899iW
-(6ݽͱXxkMK;=tﮅ)KXaEPEPEP=:4x_Ã:SG'p8֎؉]Y5]}{ֻntOqn|[].z/j"5ƪAzd 7R|6o=,O,VX?58tEյ	iaah.{rn̍ ̰WcMm6-{OG%H+_xŷ/"̥"3)֩+{zZ"RRoF}7]Grk_%j|eƺaiេYݣx{4goOj|E:4_ZE.=Ͻom8M'hs@6?厞@1QZsVSm(h="Y_kk{u9+'_&PI[ek+nv}_:;Ju"Ak2B((((sH'}2Hcm$^G:_xui3OxSY4?ćG!.g`=VRڑm]ZQJ1N%޻k\=?k^/km]߭f~_CI׆jT@O<Iᯉ?@u_3/Wn|Ϋx0eAlB#܃hN>RW `|? c>7<?%8|2?,<_ω !x>0񖺣~xĚީX2K[r,OҸ(EP#P p>U=Ofa]: V昋EK}~uV|a~}3?Y^?W>[Yç99$$(ۧ_&S}WπbBoڻC}@^c>)lmma~Q޾Ǝ!XP=Oc~:w@63eNd?f zmD 25ZE$g(Oэ(\(G*82@;3lDl~:Zk̗D-miE߻U޶~AiK\ QI 1@H'>ڭZW&J]~kg|YUᯌK/PA(fִ˛9M4SZoVSBx%$_<g ~sm/_
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' |N&f@91z}j1MSKDm6W{S1I+>68!EAP& \(qWOJ:;}5$=N988 cW,&5^Fޗ9''y= 7ESQE QE QE QE                                                             t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                               e     C h e c k 5                         t   D                                                                     T e x t 1                           t   D                                                                     T e x t 2                           t   D                                                                     T e x t 3                           t   D                                                               e     C h e c k 6                         t   D                                                               e     C h e c k 7                         t   D                                                               e     C h e c k 8                         t   D                                                               e     C h e c k 9                         t   D                                                                     T e x t 4                           v   D                                                                     T e x t 1 6                           v   D                                                               e     C h e c k 1 0                         t   D                                                                     T e x t 6                           v   D                                                               e     C h e c k 1 1                         t   D                                                                     T e x t 5                           v   D                                                               e     C h e c k 1 2                         v   D                                                               e     C h e c k 1 3                         t   D                                                                     T e x t 7                           t   D                                                                     T e x t 8                           t   D                                                                     T e x t 9                           v   D                                                                     T e x t 1 5                           v   D                                                                     T e x t 1 1                           v   D                                                               e     C h e c k 1 8                         v   D                                                                     T e x t 1 2                           v   D                                                                     T e x t 1 3                           v   D                                                               e     C h e c k 1 4                         v   D                                                               e     C h e c k 1 5                         v   D                                                                     T e x t 1 4                           v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                                                                                                                                                     
  i           @  @ @   N o r m a l        CJ OJ QJ _HaJ mH	sH	tH	> @  >  	 H e a d i n g   1     $$@& a$ CJ  OJ QJ                 < A@ <   D e f a u l t   P a r a g r a p h   F o n t             , @  ,   H e a d e r      !   ,    ,   F o o t e r      !           T        /   0   1   2   A   X   n                                 	  
        1  I  ]  ^  _  `  j                          8  L  M  N  O  e  }                          #  $  %  &  :  N  O  P  Q  e  f  g  h                                  1  2  3  4  5  D  X  r                                H  I  J  K  L  M                                      ,  -  .  /  0  1  e  f  g  h  i  j                               0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @  0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0             0              0          @   0          @   0          @  0          @   0          @   0          @   0          @   0              0              0          @   0          @   0              0              0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @  0          @   0          @   0          @   0          @   0          @   0          @   0          @   0          @   0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0              0                                                                        
     N  Q    
               #   '                  v	  	  B
  
  
  f            !      ;  w                                                          !   "   $   %   &   (   )           A   Q   X   h   n   ~                        )  /  I  U  [  j  z                  	  8  D  J  e  u  }                            !  :  F  L  Q  ]  c                    )  /  D  P  V  X  h  r            $  0  @  M  ]  i  y                        $  1  A  M  ]  j  z                G$G$G$G$G$FTFTFTG$G$G$G$FTFG$FTG$FTG$G$FTFTFTFFTG FTFTG$G$FTG G G G G G G G G G G G G G G G   l                          ,   R $   ZP-      "T    @                          J   (    	                    
            
      
  c    A            .     @ H : \ R e s p i t e   G r a n t \ M a r k e t i n g \ l 2 i f e s p a n   r e s p i t e   l o g o P u r p l e & G r e y . J P G          S  `T  S  `T           "                        B    
        S              	   ?                  h    8       !    C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  T e x t 1  T e x t 2  T e x t 3  C h e c k 6  C h e c k 7  C h e c k 8  C h e c k 9  T e x t 4  T e x t 1 6  T e x t 5  T e x t 6  C h e c k 1 0  C h e c k 1 1  C h e c k 1 2  C h e c k 1 3  T e x t 7  T e x t 8  T e x t 9  T e x t 1 5  T e x t 1 1  C h e c k 1 8  T e x t 1 2  T e x t 1 3  C h e c k 1 4  C h e c k 1 5  T e x t 1 4  C h e c k 1 6  C h e c k 1 7 B   Y   o              J  k          9  P  P  f          ;  R          E  Y  s      1                                	   
                                                                      R   i              0  \  {        
  K  v            "  M  d        0  W  i      %  A              	 D H H S   U s e r < H : \ R e s p i t e   G r a n t \ F a m i l y   A p p l i c a t i o n \ F a m i l y   R e f e r r a l   F o r m . d o t     2   A   X   n                                 	  
        1  I  ]  ^  _  `  j                          8  L  M  N  O  e  }                          #  $  %  &  :  N  O  P  Q  e  f  g  h                                  1  2  3  4  5  D  X  r                                H  I  J  K  L  M                                      ,  -  .  /  0  1  e  f  g  h  i  j                                                                                                                                                                                                                                                                                                                                                            @X               *  *    p   @  p      p      p  
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of New Hampshire                      #	                                     Family Referral Form            Title                        8      @            _PID_HLINKS      A            b                   A   H : \ R e s p i t e   G r a n t \ M a r k e t i n g \ l 2 i f e s p a n   r e s p i t e  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                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r   s   t   u   v   w   x   y   z   {   |   }   ~                                                                                                                                                      R o o t   E n t r y                                                 	           F             "Q          D a t a                                                         
                                              1 T a b l e                                                                                                 "      W o r d D o c u m e n t                                                                                              S u m m a r y I n f o r m a t i o n                           (                                                D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                                   C o m p O b j                                                                                                j       O b j e c t P o o l                                                                    "Q "Q                
  	           F   Microsoft Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                                  