LETTER OF INTENT

Please complete the following form to communicate to future caregivers and trustees what you think they need to know to care for you or your loved one. Regardless of where the person with a disability lives – in a group home, a parent’s or family member’s home, or his or her own home, you or the parent (spouse or other family caregiver) should indicate what you know best based upon a lifetime of your care. You can pass on the information to succeeding caregivers. These instructions should be given to successor caregivers (and trustees) after they have agreed to serve as well as kept in the special needs trust attorney’s file. Sharing the instructions is best done though a meeting to review the Letter after it is completed. This Letter of Intent is designed to give successor caregivers and trustees the realistic information they need to carry on effectively as caregivers after parents (or other family caregivers) no longer can provide the care themselves. This practical information could also alleviate concerns that caregivers and trustees might have about how they best can fulfill expected family obligations. It is advisable to revisit this Letter of Intent on an annual basis to account for changes which might have transpired. To read more about why this document is important please read our guide.

Client Information

Your First Name

Your Last Name

What email do we send the completed form to?

Date

Letter of Intent

Date Written / Revised

Address the letter to whomever you wish

General Information

First Name of Child

Middle Name

Last Name

Are there any other names you or your child have used throughout his or her lifetime under which your child's information may be listed or records might be kept?

Current address

Child's former address

Child's former phone numbers

Date of Birth

Social Security Number

Phone Number

Diagnosis of Individual with Disability

Mother SSN

Father SSN

Sibling SSN (if needed)

Two people who know the most information about the child, other than parents or current caregivers.

Person #1 Name

Person #1 Phone

Person #1 Address

Person #2 Name

Person #2 Phone

Person #2 Address

Stepparents (current or previous)

Former Spouses

Citizenship Status (if other than US born citizen)

Medical Information

What type of medical insurance does your child have? List all types, companies and policy numbers, including private insurance, Medicaid and Medicare.

Is insurance on parent's or guardian's account?

What are plans for continuing after death of parent or guardian?

Any dental or vision coverage? If so, identify the company.

Type of Coverage

Group Number

Identification Number

Medication List

Name of Medication	Purpose	Doctor's Name

Is he/she allergic to any medications, insect bites, chemicals, or any other item? If yes, please list and explain type of reaction and treatment required.

What non-prescription medications or vitamins does he/she take?

Name of Medication	Purpose

Provide any special instructions or procedures to follow when taking him/her to a doctor or dentist:

In the event of an emergency, are there any special instructions?

Professional Contacts for Disabled Beneficiary

Attorney

Address

Phone

Trustee of Special Needs Trust

Address

Phone

POA for Finances

Address

Phone

POA for Healthcare

Address

Phone

Guardian

Address

Phone

Clergy

Address

Phone

School (if Applicable)

Address

Phone

Employer (if Applicable)

Address

Phone

Financial Planner

Address

Phone

Insurance Agent

Address

Phone

Primary Care Physician

Address

Phone

Pharmacy

Address

Phone

Mental Health Professional

Address

Phone

Waiver Contacts

Address

Phone

Resource Coordinator

Address

Phone

Respite Providers

Address

Phone

Other Therapists and Doctors

Name	Address	Phone Number

Personality Traits and Preferences

Describe in general terms what living with your child is like.

Describe his/her basic characteristics and personality.

Does the individual need any assistance with personal care? If yes, please explain what assistance is needed.

Please list the person's favorite type of clothes / favorite materials.

Clothing and Accessory Sizes

Shoe

Gloves

Underwear

Pants

Skirt/Dress

Belt

Shirt

Coat

Other

Height

Weight

Food Preferences

Please share comments or information about meals, food preparation, or eating habits.

Please list foods that the individual does not like or will not eat (i.e., broccoli or fried foods).

Is the person unable to feed self, or needs limited help at meals (for example, he/she cannot cut up his or her food or lift eating utensils)? If yes, please explaini what help is needed.

Is he/she allergic to any foods? If yes, please identify.

List any additional comments.

Daily Routine

Describe his/her daily routine (for example, gets up at 7AM, drinks coffee until 7:30AM, eats breakfast at 8AM, etc.)

Morning

Time	Description

Afternoon

Time	Description

Evening

Time	Description

Activities and Interests

Activities/Interests (i.e., sport events, shopping malls, grocery stores, or theaters).

Does he or she attend a church / synagogue? Religious Affiliation?

What activity does your child particularly like or dislike? Think also about other likes and dislikes (food, hobbies, etc.).

Favorite places to visit in the community where people are familiar:

Who are your child's friends and their parents (include contact information)?

Friend Name	Parent Name(s)	Contact Information

Special Services and Needs

How does your child react during stressful times? Are there certain things that someone should know about helping your child through particularly stressful times or transitions in your child's life? Is there a particular person who can provide comfort in an emergency (clergy, friend)?

Special supports and services currently receiving:

Who provides them, how are they paid?

Have you applied for special supports and programs including public benefits? If so, are you receiving the full amount of SSI?

Are you currently on a waiting list for any service? Include the name of the service, contact person, phone number, date and status of application.

Are you currently undergoing an Appeal with Social Security? Include the contact person, phone number, date and status of the Appeal.

The Future

Describe your idea of what life would look like for your child in the future.

What things are most important to you?

What things are most important to your child?

Where would he/she live?

What would he/she do during the day?

What type of help or support would you envision?

What types of activities would he/she enjoy most?

What types of employment/volunteer work would you suggest be explored?

Identify friends/relatives who may be able to play a role in your child's life (make sure you also discuss this with those individuals and your child). Include contact information.

Identify any people, including relatives, who you would NOT want to play a role in your child's life.

Provide the name of the person (and alternates if possible) who you prefer to be a primary advocate and a friend for your child.

If your child is expected to receive day, residential or other supports from an agency, are there any particular providers or other non-health care professionals you would like to be considered? Include contact information and dates of applications.

What are the three most important things you would want someone to consider when planning for your child's future?

What are the three most important things you want your child to know about your planning?

Legal and Financial

Do you have a Last Will and Testament? Where is it located?

Do you have a 3rd Party Special Needs Trust? Who is the Trustee and where can the document be found? Include contact information.

Do you have a 1st Party Special Needs Trust? Who is the Trustee and where can the document be found? Include contact information.

If you envision your child living in the family home, what arrangements have been made regarding that home (ownership, title, etc.) and where can those documents be found? What financial arrangements have you made to provide funds for maintenance and other upkeep on the home, while considering the effect on your child's eligibility for public benefits?

If your child is under 18 years old, list your first and second choice for legal guardian with contact informaiton.

If your child is an adult, who currently consents to medical care?

If your child consents to medical care, does he/she need some assistance with decisions? If so, who would you suggest to provide this assistance? If you currently provide consent to medical care (either formally or informally) who would you suggest assume this role?

Have you made any funeral arrangements for your child? Do you have any special wishes? Describe.

If your child is under 18 years old, who would be your choices to help manage your child's money or public benefits?

Who would be your second choice? Please include contact information.

If your child is over 18 years old, how does he/she handle finances at this time?

What assistance does he/she receive?

Who would be your first choice to provide this assistance? Please include contact information.

Who would be your second choice to provide this assistance? Please include contact information.

If there is already a representative payee (financial representative) list their contact information.

Assets

Financial Institutions

Name	Address	Type of Accounts	Date of Inception	Owners	Amount

List any life insurance policies that name your child (or a trust established for your child) as either the beneficiary or insured. Provide the name of the company, status of your child (owner, beneficiary, other) and contact information, and amount of insurance.

Does your child receive Social Security Supplemental Security Income (SSI) or other cash benefits? If so, list type and amount.

Type	Amount

Does your child have a representative payee for any of these benefits? If so, which benefits? List contact information for each representative payee.

If you are the representative payee, do you have a preference as to the person who would be designated if you were unable to serve? Provide contact information.

If your child has been employed, where has he/she worked?

Records

List any schools your child has attended.

School Name	Notes

Location of birth certificate, social security card, etc.:

Attach any relevant evaluations that clarify their disability and needs:

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LETTER OF INTENT

Client Information

Letter of Intent

General Information

Two people who know the most information about the child, other than parents or current caregivers.

Medical Information

Professional Contacts for Disabled Beneficiary

Personality Traits and Preferences

Clothing and Accessory Sizes

Food Preferences

Daily Routine

Activities and Interests

Special Services and Needs

The Future

Legal and Financial

Assets

Records

Office Location