Respite Form

 

Fee Schedule

  • NET INCOME 4 HOURS 4:01 - 6 HOURS 6:01-8 HOURS
    Above $150,000 $25.00 Per Hour $25.00 Per Hour $25.00 Per Hour
    NET INCOME 4 HOURS 4:01 - 6 HOURS 6:01-8 HOURS
    $100,000-$149,999 $35.00 Per Visit $45.00 Per Visit $55.00 Per Visit
    $50,000-$99,999 $25.00 Per Visit $30.00 Per Visit $35.00 Per Visit
    $25,000-$49,999 $10.00 Per Visit $12.50 Per Visit $15.00 Per Visit
    Under $25,000 $5.00 Per Visit $5.00 Per Visit $5.00 Per Visit
 

Child's Information

 

Information

 

Verification

 
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