What is the respite care request form template?
Family carers often wait too long to ask for a break, and when they do, the respite provider has to gather a lot of information quickly: who the person is, how much help they need, what their day looks like and who to call. This request form collects that in one go and saves it as a signed PDF in your FileIt vault.
The carer gives their own details and relationship, then the name, date of birth and address of the person they look after. The break page asks for start and end dates, whether the dates are flexible, and "What kind of respite are you looking for?" — an overnight stay in a care home, carer visits or a live-in carer at home, day centre sessions or a sitting service — plus the reason and how it will be paid for.
The care-needs page has a grid, "How much help do they need with each of these?", covering washing, dressing, toileting, eating, medication, getting around and nights, followed by memory, communication, medication and allergies. A typical day, likes and dislikes, backup contacts and two consents finish the form, so the care team has a full picture before the first day.
- Best for
- Care homes, home care agencies, day centres and carers' organisations
- Filled in by
- The family carer
- Time to complete
- About 10 minutes
- Includes
- Dates and respite type, support grid, routine, medication upload, backup contact, signature
Who uses a respite care request form?
- A husband books a two-week care home stay for his wife while he has surgery
- A daughter arranges carer visits at home so she can take a holiday
- A carers' charity collects requests for a sitting service
- A day centre takes on a new attendee for weekly sessions
- A parent of an adult with learning disabilities plans a short break
- An agency receives an emergency respite request when a carer falls ill
Questions on this respite care request form
35 questions over 5 pages · includes signature, file upload, conditional questions, multiple pages, consent checkbox, ratings.
1 You & the person you care for
- Your name*
- Email*
- Phone*
- Your relationship to the person you care for*
- Their name*
- Their date of birth*
- Their address
- Their doctor or GP practice
2 The break you need
- Respite start date*
- Respite end date*
- Are your dates flexible?
- What kind of respite are you looking for?* Overnight stay in a care home · Carer visits at home · Live-in carer at home · Day centre sessions · Sitting service for a few hours
- Which days and hours?* asked only when it applies
- Reason for the break A planned holiday or rest · My own health or hospital stay · Work or family commitments · Emergency · Prefer not to say
- How will it be paid for? Self-funded · Local authority or council · Health funding · Insurance · Not sure yet
3 Care needs
- Main health conditions or diagnoses*
- Mobility* Walks independently · Walks with a stick or frame · Uses a wheelchair · Needs help to transfer · Needs a hoist
- How much help do they need with each of these?* None · Prompting · Some help · Full help
- Do they have memory problems or dementia?*
- How does it affect them day to day?* asked only when it applies
- Communication Communicates well · Hard of hearing · Sight loss · Speech difficulty · Uses gestures or signs · Speaks another language
- Which language? asked only when it applies
- Medication, doses and times
- Medication list or care plan
- Allergies and dietary needs
4 Routines & preferences
- A typical day
- Things they enjoy, and things that upset them
- Preference for the gender of carers No preference · Female carers · Male carers
- Are there pets at home that need care? asked only when it applies
5 Contacts & consent
- Can we reach you during the break?* Yes, any time · Yes, but only for urgent matters · No — please use the backup contact
- Backup contact name*
- Backup contact phone*
- Sharing information*
- Their agreement*
- Signature*
The respite care request form, page by page
1 You & the person you care for
The carer's name, email, phone and the required "Your relationship to the person you care for". Under a heading, the person's name and date of birth (both required), their address and their doctor or GP practice.
2 The break you need
Required start and end dates, "Are your dates flexible?", and the required "What kind of respite are you looking for?" with an Other option — choosing carer visits at home asks which days and hours. Then the reason for the break and "How will it be paid for?".
3 Care needs
Required free text for main health conditions, a required mobility choice from walking independently to needing a hoist, and the required grid "How much help do they need with each of these?" — none, prompting, some help or full help across seven areas. "Do they have memory problems or dementia?" asks how it affects them day to day. Communication needs (with the language if they speak another), medication, an optional upload of a medication list or care plan, and allergies and dietary needs.
4 Routines & preferences
"A typical day", things they enjoy and things that upset them, a preference for the gender of carers, and — unless the respite is in a care home — whether there are pets at home that need care.
5 Contacts & consent
The required "Can we reach you during the break?" and a required backup contact name and phone. A placeholder paragraph for your service information, required consents to share the information with the care staff and confirming the person agrees or the carer can act for them, and the carer's signature.
Make the template yours
- Remove respite types you don't offer, or add your own named services
- Replace the placeholder paragraph with your fees, what to bring and cancellation policy
- Change the support grid rows to match your own care assessment
- Add a question about a lasting power of attorney if your service needs it
- Set a maximum number of responses for a limited number of respite beds
- File requests in a vault folder per service or location
Tips for a better respite care request form
- Encourage carers to fill in "A typical day" in detail — it's what helps someone settle
- Ask for the medication list as a photo; it's quicker and avoids copying errors
- Call the carer to talk through the request before confirming
- Keep the backup contact current for every stay
- Send the form well before school holidays, when demand is highest
Every response becomes a PDF in your vault
Each request is saved as a signed PDF in your vault, with any medication list or care plan filed as an attachment. Your team is emailed, and the carer can receive a copy of what they submitted.
Use the Responses table to see requests in date order and search by the carer's name. Export to CSV to plan respite beds or carer rotas across the coming months.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Respite care request form: frequently asked questions
Is this respite care request template free?
Yes. It's included in the FileIt Forms app on every account, and every question can be changed.
Who fills in the form — the carer or the person being cared for?
The family carer. The form asks for their details first, then the details of the person they look after.
Does the form confirm a respite place?
No. It's a request. The provider reviews it and confirms dates and arrangements directly.
Can carers upload a care plan?
Yes. There's an optional upload for up to three files, such as a medication list or an existing care plan, filed as attachments of the PDF.
Is the form signed?
Yes. The carer signs at the end, after two consents about sharing information and the person's agreement.
Does the carer need a FileIt account?
No. They fill it in from a link or an emailed request.