Letter of Intent Questionnaire - The Law Office of Randy Hope Steen, LTD.

Client Information

Your Name

First Last

Email(Required)

Phone

Address this letter to whom you wish

Is there a secondary preparer for this letter?

First Last

General Information

Name of Person with Disability

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 and phone number:

Child’s former addresses and phone numbers:

Diagnosis of Disability

Date of Birth

Important Caregivers

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

Person #1 Name / Address / Phone

Person #2 Name / Address / Phone

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

Medication / Purpose

Doctor's Name

Limit of 4

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 (indicate the purposes) take?

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

Attorney Name, Address, and Phone Number

Trustee of Special Needs Trust Name, Address, and Phone Number

POA for Finances for Disabled Beneficiary Name, Address, and Phone Number

Healthcare POA for Disabled Beneficiary Name, Address, and Phone Number

Guardian for Disabled Beneficiary Name, Address, and Phone Number

Clergy Name, Address, and Phone Number

School (if applicable) Name, Address, and Phone Number

Employer (if applicable) Name, Address, and Phone Number

Financial Planner Name, Address, and Phone Number

Insurance Agent Name, Address, and Phone Number

Primary Care Physician Name, Address, and Phone Number

Other Therapists Name, Address, and Phone Number

Pharmacy Name, Address, and Phone Number

Mental Health Professional Name, Address, and Phone Number

Waiver Contacts Name, Address, and Phone Number

Resource Coordinator Agency Name, Address, and Phone Number

Respite Providers

Personality Traits and Preferences

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

Describe his/her basic characteristics and personality:

Daily Routine

Describe his or her daily routine (for example, gets up at 7AM, drinks coffee until 7:30 AM, eats brakfast at 8 AM):

Morning

Afternoon

Evening

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:

Height

Weight

Clothing Size

Provide the person's shoe and clothing sizes

Shoes

Pants

Shirts

Skirt / Dress

Coat

Gloves

Underwear

Belt

Other

Food Information

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

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

List any additional food-related comments:

Please list foods that the individual does not like or will not eat:

Is the person unable to feed self, or needs limited help at meals? If yes, please explain:

Activities

Activities/Interests (i.e., sports 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)?

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)?

Benefits and Support

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 the 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 the most?

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

Important People

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 three of the 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 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 information.

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 his finances at this time?

What assistance does he/she receive?

Who would be your first choice to provide this assistance?

Who would be your second choice?

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

Bank Accounts

List all bank accounts and other financial resources titled in your child's name, or held on your child's behalf:

Names and addresses of financial institutions:

Types of accounts and date of inception:

All owners on the account:

Approximate amount in the account:

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 Insurance (SSI) or other cash benefits? If so, list type and 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 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 attended:

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

Attach any relevant evaluations that clarify their disability and needs:

Letter of Intent