Rehabilitation Research and Training Center
On Aging and Developmental Disabilities
Department of Disability and Human Development
University of Illinois at Chicago
1640 West Roosevelt Road
Chicago, Illinois 60608-6904
Family Future Planning:
Training, Support and Advocacy Program
for Adults with Developmental Disabilities and Their Families
Letter of Intent
Section One: General Information
Date: ______
Name of person with a disability: ______
Authors of this letter of intent (indicate relationship to person with disability):
______
______
Contact information for person with disability
Address: ______
______
Phone: ______
Date of Birth: ______Place of Birth: ______
Name(s) of primary caregiver(s):______
Address: ______
______
Phone: ______
1
Our Story (where parents were born, where met, stories of individual’s birth and
childhood, individual’s schooling, other siblings’ stories, and any other material you wish
to include):
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
2
_______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
3
Naming the Dream and Nightmare
My family’s dream is: ______
______
______
______
My family’s nightmare is: ______
______
______
______
My family member’s dream is: ______
______
My family member’s nightmare is: ______
______
______
______
______
______
______
______
4
Section One: Goal and Our ‘To Do’ List
Goal: Our relative’s future dream:
______
______
______
______
______
______
Our ‘To Do’ List:
Specify the actions you should take to achieve this goal.
1. ______
2. ______
3. ______
4.______
5.______
5
Section Two: Building Relationships and Skills
Family members who are important to our relative:
Name Address Phone Relationship
______
______
______
______
______
______
______
______
Close friends who are important to our relative:
Name Address Phone Common Interests
______
______
______
______
______
______
______
______
6
Family Culture
Our family celebrates the following events (birthdays, holidays, anniversaries): ______
______
______
______
______
______
Our family celebrates events by: ______
______
______
______
______
______
______
Other cultural / ethnic information: ______
______
______
______
______
______
______
7
Strengths and Preferences
My family member: ______
Places my family member likes to be, or that make sense to try (e.g., places that create
enthusiasm, motivation, energy): ______
______
What my family member enjoys: ______
______
My family member can do these things (competencies or abilities): ______
______
______
My family member would like to be/learn these things (new competencies):
______
______
These things are important to my family member (e.g., family identities and traditions, religious
beliefs, relationships, indoor/outdoor activity preferences, day or night, structured or relaxed
environment, quiet/noisy setting):
______
______
______
These are the best things about my family member (personal qualities, life-shaping experiences):
______
8
Disposition:
My (our) relative’s disposition is generally: (i.e. happy, playful, quiet, withdrawn, assertive,
passive, easily influenced, etc.) ______
______
______
______
My (our) relative might become upset / violent if: ______
______
______
______
______
______
This is how we calm / comfort him/her: ______
______
______
______
______
Communication
My (our) relative uses speech to communicate Yes ____ No ____
Special information about my (our) relative’s communication:
______
______
9
Habits and routines
My (our) relative is used to the following routines: ______
______
______
______
______
______
______
______
______
______
______
My (our) relative has the following habits: ______
______
______
______
______
______
______
______
______
10
Section Two: Goal and Our ‘To Do’ List
Goal: Expand and strengthen our relative’s friendship and support networks:
______
______
______
______
______
______
Our ‘To Do’ List:
Specify the actions you should take to achieve this goal.
1. ______
2. ______
3. ______
4. ______
5. ______
11
Section Three: Housing
Current living arrangement: ______
______
______
Desired future living arrangement:
______
______
______
List what is important in terms of location, transportation, grocery store, family members and
friends’ homes, etc. ______
______
______
List types of places that would need to be conveniently reached from your relatives’ home?
______
______
Level of independence
Level of mobility (e.g., ambulatory, wheelchair): ______
______
How residence needs to be adapted (ramp, grab bars, etc): ______
______
Household tasks that s/he can perform independently: ______
12
Household tasks that s/he will need help with: ______
______
Assistance needed with public transportation, shopping, hiring and firing own personal care
assistants: ______
______
______
Relative with a disability makes the following choices (clothing, spending allowance, pick out
videos, etc):
______
______
______
Personal Possessions
Important items for my (our) relative to have at his/her home: (i.e. collections, TV/VCR, stereo,
etc.)
______
______
______
______
Personal Care
My (our) relative appreciates assistance with the following personal care tasks: ______
______
______
13
My (our) relative is able to do the following personal care tasks alone: ______
______
______
My relative is used to the following personal care items (i.e. brands of shampoo, soap,
toothpaste, razor, etc.): ______
______
______
______
My (our) relative is used to the following personal care routine: ______
______
______
______
______
______
Height: ______Weight: ______Clothing Size: ______Shoe Size: ______
Describe how you best reinforce your relative’s self-esteem: ______
______
______
______
______
______
14
Food and Eating
My (our) relative is able to do the following food preparation and clean up: ______
______
______
Assistance needed: ______
______
______
My (our) relative likes the following foods: ______
______
______
My (our) relative dislikes the following foods: ______
______
______
Special information regarding food and my (our) relative: ______
______
______
Family customs regarding food: ______
______
______
______
15
Section Three: Goal and Our ‘To Do’ List
Goal: Our relative’s desired future living arrangement:
______
______
______
______
______
______
Our ‘To Do’ List:
Specify the actions you should take to achieve this goal.
1. ______
2. ______
3. ______
4. ______
5. ______
16
Section Four: Postsecondary Education, Work, and Retirement
Current education, work, or retirement activities (include organization name and contact person):
______
______
______
Desired activity: ______
______
______
______
Important information regarding future plan: ______
______
______
Community Activities
Leisure and Recreation
Structured activities that are enjoyed Special things to know (special assistance,
friends to go with, and location of activity)
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
17
Activities my (our) relative does not like: ______
______
______
______
Unstructured activities (collections,
music, TV shows, interests)
Special things to know
Vacations (past ones and future dreams): ______
______
______
Fitness Program or Health Club: ______
______
______
18
Voting: ______Absentee ballot ______In person ______
Library member: ______If YES, specify branch and location:
______
Clubs: ______
______
______
______
Religious or spiritual needs
Current religious institution affiliation (name, address and phone): ______
______
______
How has individual participated in religious community? ______
______
______
What aspects of religion/spirituality are important?______
______
______
Funeral Arrangements (burial, cremation, cemetery plot, financial plan, type of service):
______
______
______
19
Section Four: Goal and Our ‘To Do’ List
Goal: Our relative’s postsecondary education, work, or retirement:
______
______
______
______
______
______
Our ‘To Do’ List:
Specify the actions you should take to achieve this goal.
1. ______
2. ______
3. ______
4. ______
5. ______
20
Section Five: Who will be the keeper of the dream?
Our family, including our relative with a disability, has chosen the following person as the
successor caregiver: (name of person with contact information)
______
______
Our Relative’s Medical Care:
Diagnosis: ______
______
Current Doctors Address Phone Experience with Doctor andRoutine of Care
Medications:
Name of Medication Dosage What is it for? Prescribed by?
21
Doctors not to go to (Explain why): ______
______
______
Medical services and therapies: ______
______
______
Dentist: ______
______
Allergies: ______
______
Ophthalmologist and Audiologist: ______
______
Important information regarding vision, hearing, devices, or special equipment: ______
______
______
Important information regarding seizures: ______
______
Past operations / conditions: ______
______
Sleeping habits: ______
Other important medical information (Genetic testing, immunizations, birth control):
______
22
Education history of family member with disability
School Name Dates Comments
______
______
______
______
______
My (our) relative has a current Individual Education Plan (IEP):
Yes _____ No _____ Not Applicable ______
Important information about the IEP: ______
______
______
______
My (our) relative currently has a transition plan:
Yes ____ No _____ Not Applicable ______
Important information regarding the transition plan: ______
______
What are the future educational needs of my adult relative with a disability? ______
______
______
Why is this important to the family member with a disability? ______
______
23
Financial/Legal Plans
I (we) have developed a special needs trust for my (our) relative: Yes ____ No ____
Important information regarding my (our) relative’s special needs trust: ______
______
______
What to spend it on? How often? How much?
The Trustee of his/her trust is (Name, address, and phone): ______
______
______
The Advisor of the trust is (Name, address, and phone): ______
______
______
Guardian (Name, address, and phone): ______
______
______
Successor Guardian: ______
______
24
Power of Attorney: ______
______
Successor Power of Attorney: ______
______
My (our) relative has a will? Yes ____ No ____Where is it located? ______
______
My (our) relative has an advance directive for healthcare? Yes ____ No ____
Describe: ______
Financial Information
Representative Payee (Name, address and phone): ______
______
Receives SSI ____ Current Amount: ______Medicaid Number: ______
Receives SSDI ____ Current Amount: ______Medicare Number: ______
Other income or assistance: ______
______
Banking
Bank/Credit Union Name: ______
Address: ______
Contact person and phone: ______
Savings Account Number: ______
Checking Account Number: ______
25
Paychecks
Amount of paychecks: ______
______
Uses paychecks for: ______
______
Does own banking: Yes _____ No ____
Specific assistance needed: ______
______
Tax Information
Accountant Name: ______
______
Can do own taxes: Yes ____ No ____
Specific assistance needed: ______
______
______
______
26
Section Five: Goal and Our ‘To Do’ List
Goal: Designate a Successor Caregiver:
______
______
______
______
______
______
Our ‘To Do’ List:
Specify the actions you should take to achieve this goal.
1. ______
2. ______
3. ______
4. ______
5. ______
27
Goal to Achieve in the Next Three Months
Families including their relative with a disability are to take the goals they
have established in Sections 1-5 and prioritize them in order of importance.
Goal Priority 1 is the goal you will work on in the next three months:
Goal Priority 1:
______
______
Goal Priority 2:
______
______
Goal Priority 3:
______
______
Goal Priority 4:
______
______
Goal Priority 5:
______
______
28
Other Information
Other information that you would like to add about your relative:
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
29
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
______
30