Our Letter of Intent for our Loved One
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- Aron Nickolas Cobb
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1 Our Letter of Intent for our Loved One
2 The Letter of Intent As part of the special needs planning process, you should complete a Letter of Intent. Although this is not a legally binding document, it can help ensure that future caregivers understand your wishes for your loved one with special needs. It will also allow the caregiver to more quickly learn how to deliver the very best care possible. You should include as much detail as possible in your Letter of Intent. Draw upon what you know about your dependent through your observations and when appropriate, through discussions with him/her. Document what you have learned and update the information regularly and stored in a readily available location. The following pages are not meant to be exhaustive, and they do not cover every detail that may be important to your letter. Every person has different needs, and everyone has different wishes for their loved ones. This outline is meant only as a guide to get you started.
3 Table of Contents Information About Our Loved One With Special Needs... 2 Daily Living... 3 Recreational Preferences... 3 Personal Preferences... 3 Information About Birth Parents... 4 Information About Siblings... 5 Information About the Caregivers... 7 Preferences - Caregivers... 8 Housing Arrangements... 8 Insurance Information... 9 Government Benefits... 9 Community Services Educational Information Educational Support Team Educational History Contacts Contacts Family/Friends Contacts - Physicians Preferences - Physicians Contacts - Therapists Preferences Therapists Contacts - Nurses Preferences - Nurses Contacts Aides/Helpers Preferences Aides/Helpers Contacts - Vocational Contacts - Pharmacy Contacts Preferred Hospital Contacts Estate/Financial Contacts Estate/Financial Documents Important Legal Documents Other Important Documents Medical Information Medical Equipment Birth History Diagnoses Medical History - Immunizations Medical History - Hospitalizations Medical History Surgical Procedures Allergies - Food Allergies - Medications Allergies - Environmental Allergies - Pets Allergies - Other Medical History - Medications Additional Comments... 38
4 This Letter of Intent is to share information about our loved one with special needs (special needs dependent s name) and my/our wishes for his/her future. Attach Photo Here PREPARED BY: SIGNATURE: Relationship to Special Needs Dependent: DATE: Page 1 of 38
5 Information About Our Loved One With Special Needs CONTACT INFORMATION Full Name: Nickname: Date of Birth: Blood Type: U.S. Citizen: Yes No Race: Ancestry: Gender: Languages Spoken: Home Phone: ( ) - Cell Phone: ( ) - Religion: Work Phone: ( ) - Marital Status: INFORMATION ABOUT OUR LOVED ONE WITH SPECIAL NEEDS Single Divorced Married Domestic Partner Employer: Spouse/ Partner s Name: SOCIAL MEDIA List Type (i.e. , Facebook, etc.) Should account be monitored? Yes Yes Yes Yes No No No No Account User Name Account Password Comments HEIGHT / WEIGHT / CLOTHING SIZES Height: Weight: Shirt Size: Pants Size: Shoe Size: Items to Avoid (i.e. colors, fabrics, etc): NUTRITION* *IMPORTANT: See Food Allergies, if applicable, under the Allergies Section in this booklet Food Likes: Foods to Avoid: Page 2 of 38
6 Daily Living DAILY LIVING DAILY LIVING SKILLS (Describe current skill level and where assistance is needed) Needs Assistance Details Bathing: Yes No Cooking: Yes No Dressing: Yes No Eating: Yes No Finances: Yes No Toileting: Yes No Traveling: Yes No DAILY ROUTINES Is an instructional video attached (i.e. CD, DVD, flash drive, etc)? Yes No WEEKDAYS: Mornings: Afternoons: Evenings: WEEKENDS: Mornings: Afternoons: Evenings: Recreational Preferences RECREATIONAL PREFERENCES: RECREATIONAL PREFERENCES Current Hobbies: Favorite Recreational Activities: Vacation Preferences: Personal Preferences PERSONAL PREFERENCES: Favorite Things (pets, people, toys, etc): Social (strengths, weaknesses, & preferences): Triggers/Upsetting Things: Antidotes/Soothing Things: PERSONAL PREFERENCES Page 3 of 38
7 Information About Birth Parents INFORMATION ABOUT BIRTH PARENTS BIRTH FATHER Birth Father s Full Name: Blood Type: Ancestry: Date of Birth: U.S. Citizen: Yes No Languages Spoken: Race: Religion: Cell Phone: ( ) - Home Phone: ( ) - Work Phone: ( ) - Marital Status: Single Married Divorced Domestic Partner Significant Medical History: Employer: Spouse/ Partner s Name: BIRTH MOTHER Birth Mother s Full Name: Blood Type: Ancestry: Date of Birth: U.S. Citizen: Yes No Languages Spoken: Race: Religion: Cell Phone: ( ) - Home Phone: ( ) - Work Phone: ( ) - Marital Status: Single Married Divorced Domestic Partner Significant Medical History: Employer: Spouse/ Partner s Name: Page 4 of 38
8 Information About Siblings INFORMATION ABOUT SIBLINGS SIBLING Sibling Full Name: Sibling Type: Traditional sibling (same mother and father) Half sibling (share either same mother or father) Stepsibling (not biologically related but parents are married/domestic partners) Adopted Date of Birth: U.S. Citizen: Yes No Blood Type: Gender: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Marital Status: Single Divorced Married Domestic Partner Spouse/ Partner s Name: SIBLING Sibling Full Name: Sibling Type: Traditional sibling (same mother and father) Half sibling (share either same mother or father) Stepsibling (not biologically related but parents are married/domestic partners) Adopted Date of Birth: U.S. Citizen: Yes No Blood Type: Gender: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Marital Status: Single Divorced Married Domestic Partner Spouse/ Partner s Name: Page 5 of 38
9 SIBLING Sibling Full Name: Sibling Type: Traditional sibling (same mother and father) Half sibling (share either same mother or father) Stepsibling (not biologically related but parents are married/domestic partners) Adopted Date of Birth: U.S. Citizen: Yes No Blood Type: Gender: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Marital Status: Single Divorced Married Domestic Partner Spouse/ Partner s Name: SIBLING Sibling Full Name: Sibling Type: Traditional sibling (same mother and father) Half sibling (share either same mother or father) Stepsibling (not biologically related but parents are married/domestic partners) Adopted Date of Birth: U.S. Citizen: Yes No Blood Type: Gender: Home Phone: ( ) - Cell Phone: ( ) - Work Phone: ( ) - Marital Status: Single Divorced Married Domestic Partner Spouse/ Partner s Name: Page 6 of 38
10 Information About the Caregivers CAREGIVER(S) (if other than birth parents) Caregiver Full Name: Blood Type: Ancestry: Date of Birth: U.S. Citizen: Yes No Languages Spoken: Race: Religion: Cell Phone: ( ) - Home Phone: ( ) - Work Phone: ( ) - Marital Status: Single Married Divorced Domestic Partner INFORMATION ABOUT THE CAREGIVERS Employer: Spouse/ Partner s Name: CAREGIVER(S) (if other than birth parents) Caregiver Full Name: Blood Type: Ancestry: Date of Birth: U.S. Citizen: Yes No Languages Spoken: Race: Religion: Cell Phone: ( ) - Home Phone: ( ) - Work Phone: ( ) - Marital Status: Single Married Divorced Domestic Partner Employer: Spouse/ Partner s Name: Page 7 of 38
11 Preferences - Caregivers PREFERENCES CAREGIVER(S) AND/OR DEPENDENT S PREFERENCES Dating: Sex: Birth Control: Marriage: Religion: Work: Future Care: Future Education: Funeral/Burial: Housing Arrangements HOUSING ARRANGEMENTS PRESENT PAST FUTURE Page 8 of 38
12 Insurance Information INSURANCE INFORMATION INSURANCE INFORMATION Insurance Company Policyholder Policy # Insurance Phone Primary Medical: ( ) - Secondary Medical: ( ) - Dental: ( ) - Vision: ( ) - Other: ( ) - Government Benefits GOVERNMENT BENEFITS List government benefits your special needs dependent receives. (i.e. Social Security Income (SSI), Social Security Disability Income (SSDI), etc) Government Benefit Type : Case #: Frequency: Amount: $ Contact Name: Contact Phone: ( ) - Contact GOVERNMENT BENEFITS Government Benefit Type : Case #: Frequency: Amount: $ Contact Name: Contact Phone: ( ) - Contact STATE CASEWORKER Case #: Caseworker Name: Caseworker Phone: ( ) - Caseworker Page 9 of 38
13 Community Services COMMUNITY SERVICES COMMUNITY SERVICES List benefits/services your special needs dependent receives from the community. Name: Description: Dates of Service: / / to / / Case #: Name: Description: Dates of Service: / / to / / Case #: Page 10 of 38
14 Educational Information CURRENT SCHOOL EDUCATIONAL INFORMATION School Name: Current Grade: Contact Name: Contact Phone: ( ) - Contact School Start Time: Transportation to/from school: Transportation Contact Name & Phone: Pick-up Time/Location (include special instructions): Drop-off Time/Location (include special instructions): School End Time: Our loved one currently has: 504 Plan IEP (Individual Education Plan) IFSP (Individual Family Service Plan) Where is the Plan stored? Other comments: Page 11 of 38
15 Educational Support Team EDUCATIONAL SUPPORT TEAM CURRENT SCHOOL CHILD SUPPORT TEAM (i.e. Child Study Team, Student Study Team, Student Intervention Team, Student Success Team, etc.) Contact Name: Contact Phone: ( ) - Contact Role / Title: Contact Name: Contact Phone: ( ) - Contact Role / Title: Contact Name: Contact Phone: ( ) - Contact Role / Title: Contact Name: Contact Phone: ( ) - Contact Role / Title: Contact Name: Contact Phone: ( ) - Contact Role / Title: Contact Name: Contact Phone: ( ) - Contact Role / Title: Page 12 of 38
16 Educational History PREVIOUS SCHOOL(S) EDUCATIONAL HISTORY School Name: Last Grade Attended: Contact Name: Contact Phone: ( ) - Contact Attended from: / / to / / School Name: Last Grade Attended: Contact Name: Contact Phone: ( ) - Contact Attended from: / / to / / School Name: Last Grade Attended: Contact Name: Contact Phone: ( ) - Contact Attended from: / / to / / School Name: Last Grade Attended: Contact Name: Contact Phone: ( ) - Contact Attended from: / / to / / Comments about Schools, Teachers, Aides, etc. Page 13 of 38
17 Contacts Contacts Family/Friends FAMILY / FRIENDS CONTACTS Family/Friends Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Page 14 of 38
18 Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Family/Friend Full Name: Relationship to your dependent: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Page 15 of 38
19 Contacts - Physicians PHYSICIANS CONTACTS - Physicians Physician s Full Name: Physician s Full Name: Physician s Full Name: Physician s Full Name: Physician s Full Name: Page 16 of 38
20 Physician s Full Name: Physician s Full Name: Preferences - Physicians PREFERENCES WITH PHYSICIANS Physicians we recommend to avoid: PREFERENCES - Physicians Page 17 of 38
21 Contacts - Therapists THERAPISTS CONTACTS - Therapists Therapist s Full Name: Therapist s Full Name: Therapist s Full Name: Therapist s Full Name: Therapist s Full Name: Page 18 of 38
22 Therapist s Full Name: Therapist s Full Name: Preferences Therapists PREFERENCES WITH THERAPISTS Therapists we recommend to avoid: PREFERENCES - Therapists Page 19 of 38
23 Contacts - Nurses NURSES CONTACTS - Nurses Nurse s Full Name: Nurse s Full Name: Nurse s Full Name: Nurse s Full Name: Nurse s Full Name: Page 20 of 38
24 Nurse s Full Name: Nurse s Full Name: Preferences - Nurses PREFERENCES WITH NURSES Nurses we recommend to avoid: PREFERENCES - Nurses Page 21 of 38
25 Contacts Aides/Helpers AIDES / HELPERS CONTACTS Aides/Helpers Aide s/helper s Full Name: Aide s/helper s Full Name: Aide s/helper s Full Name: Aide s/helper s Full Name: Preferences Aides/Helpers PREFERENCES WITH AIDES/HELPERS Aides/Helpers we recommend to avoid: PREFERENCES Aides/Helpers Page 22 of 38
26 Contacts - Vocational VOCATIONAL CONTACTS - Vocational Name: Phone: ( ) - Contacts - Pharmacy PHARMACY LOCAL CONTACTS - Pharmacy Name: Phone: ( ) - PHARMACY MAIL SERVICE Name: Phone: ( ) - Contacts Preferred Hospital CONTACTS Preferred Hospital HOSPITAL PREFERRED Name: Phone: ( ) - Page 23 of 38
27 Contacts Estate/Financial Contacts Estate/Financial CONTACTS Estate/Financial ESTATE / FINANCIAL Current Guardian Full Name: Phone: ( ) - Alternate Guardian Full Name: Phone: ( ) - Trustee/Trust Full Name: Phone: ( ) - Executor/Will Full Name: Phone: ( ) - Power of Attorney Full Name: Phone: ( ) - Healthcare Proxy Full Name: Phone: ( ) - Financial Advisor Full Name: Phone: ( ) - Special Needs Attorney Full Name: Phone: ( ) - Page 24 of 38
28 Documents Important Legal Documents IMPORTANT LEGAL DOCUMENTS Established Date Established Storage Location (i.e. lockbox, safe, etc.) Date Last Updated Will Yes No / / / / Living Will Yes No / / / / Durable Powers of Attorney Yes No / / / / Guardianship Yes No / / / / Special Needs Trust Yes No / / / / Other Important Documents OTHER IMPORTANT DOCUMENTS OTHER IMPORTANT DOCUMENTS List any other important reference documentation/records that are not listed in this Letter of Intent, i.e. other binders or folders you maintain. Description Storage Location (i.e. lockbox, safe, etc.) Comments Page 25 of 38
29 Medical Information Medical Equipment TYPE & COST OF MEDICAL EQUIPMENT NEEDS (i.e. hearing aid, eyeglasses, wheelchair, etc) MEDICAL EQUIPMENT Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Type: Brand: Approx. Cost: $ Details (i.e. size, color, etc.): Supplier Name: Supplier Phone: ( ) - Page 26 of 38
30 Birth History BIRTH HISTORY BIRTH HISTORY Date of Birth: / / Weight: Length: Time of Birth: Place of Birth: Delivered by (Full Name): Birth Delivery Information: Diagnoses DIAGNOSES DIAGNOSES Diagnosis: Date diagnosed: / / Diagnosed by: Tests performed and results (include dates): Diagnosis definition: What does this diagnosis mean for our loved one? Diagnosis: Date diagnosed: / / Diagnosed by: Tests performed and results (include dates): Diagnosis definition: What does this diagnosis mean for our loved one? Diagnosis: Date diagnosed: / / Diagnosed by: Tests performed and results (include dates): Diagnosis definition: What does this diagnosis mean for our loved one? Diagnosis: Date diagnosed: / / Diagnosed by: Tests performed and results (include dates): Diagnosis definition: What does this diagnosis mean for our loved one? Page 27 of 38
31 Medical History - Immunizations IMMUNIZATIONS MEDICAL HISTORY - Immunizations Page 28 of 38
32 Medical History - Hospitalizations MEDICAL HISTORY - Hospitalizations HOSPITALIZATIONS Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Location: Results: Date(s): Page 29 of 38
33 MEDICAL HISTORY Surgical Procedures Medical History Surgical Procedures SURGICAL PROCEDURES Location: Results: Location: Results: Location: Results: Location: Results: Location: Results: Location: Results: Location: Results: Date(s): Date(s): Date(s): Date(s): Date(s): Date(s): Date(s): Page 30 of 38
34 Allergies - Food FOOD ALLERGIES ALLERGIES - Food List Known Food List Known Food List Known Food List Known Food List Known Food Page 31 of 38
35 Allergies - Medications DRUG ALLERGIES ALLERGIES - Medications List Known Drug List Known Drug List Known Drug List Known Drug Page 32 of 38
36 Allergies - Environmental ALLERGIES - Environmental ENVIRONMENTAL ALLERGIES (i.e. seasonal, cleaning solutions, insect bites, etc) List Known Environmental List Known Environmental List Known Environmental List Known Environmental List Known Environmental Page 33 of 38
37 Allergies - Pets PET ALLERGIES ALLERGIES - Pets List Known Pet List Known Pet List Known Pet Page 34 of 38
38 Allergies - Other (OTHER) ALLERGIES ALLERGIES - Other List Other Known List Other Known List Other Known List Other Known Page 35 of 38
39 Medical History - Medications MEDICAL HISTORY - Medications MEDICATIONS Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Page 36 of 38
40 Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Medication Name: Currently Taking: Yes No Dosage: Date Prescribed: / / Prescribed by: Page 37 of 38
41 Additional Comments ADDITIONAL COMMENTS Use this area to share any other thoughts or feelings about your loved one that would help to reflect the quality of care that you have provided for your special needs dependent Massachusetts Mutual Life Insurance Company (MassMutual), Springfield, MA All rights reserved. SC Page 38 of 38
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