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):

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Contact information for person with disability

Address: ______

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Phone: ______

Date of Birth: ______Place of Birth: ______

Name(s) of primary caregiver(s):______

Address: ______

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Phone: ______

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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):

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Naming the Dream and Nightmare

My family’s dream is: ______

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My family’s nightmare is: ______

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My family member’s dream is: ______

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My family member’s nightmare is: ______

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Section One: Goal and Our ‘To Do’ List

Goal: Our relative’s future dream:

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Our ‘To Do’ List:

Specify the actions you should take to achieve this goal.

1. ______

2. ______

3. ______

4.______

5.______

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Section Two: Building Relationships and Skills

Family members who are important to our relative:

Name Address Phone Relationship

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Close friends who are important to our relative:

Name Address Phone Common Interests

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Family Culture

Our family celebrates the following events (birthdays, holidays, anniversaries): ______

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Our family celebrates events by: ______

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Other cultural / ethnic information: ______

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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): ______

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What my family member enjoys: ______

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My family member can do these things (competencies or abilities): ______

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My family member would like to be/learn these things (new competencies):

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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):

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These are the best things about my family member (personal qualities, life-shaping experiences):

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Disposition:

My (our) relative’s disposition is generally: (i.e. happy, playful, quiet, withdrawn, assertive,

passive, easily influenced, etc.) ______

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My (our) relative might become upset / violent if: ______

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This is how we calm / comfort him/her: ______

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Communication

My (our) relative uses speech to communicate Yes ____ No ____

Special information about my (our) relative’s communication:

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Habits and routines

My (our) relative is used to the following routines: ______

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My (our) relative has the following habits: ______

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Section Two: Goal and Our ‘To Do’ List

Goal: Expand and strengthen our relative’s friendship and support networks:

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Our ‘To Do’ List:

Specify the actions you should take to achieve this goal.

1. ______

2. ______

3. ______

4. ______

5. ______

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Section Three: Housing

Current living arrangement: ______

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Desired future living arrangement:

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List what is important in terms of location, transportation, grocery store, family members and

friends’ homes, etc. ______

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List types of places that would need to be conveniently reached from your relatives’ home?

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Level of independence

Level of mobility (e.g., ambulatory, wheelchair): ______

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How residence needs to be adapted (ramp, grab bars, etc): ______

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Household tasks that s/he can perform independently: ______

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Household tasks that s/he will need help with: ______

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Assistance needed with public transportation, shopping, hiring and firing own personal care

assistants: ______

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Relative with a disability makes the following choices (clothing, spending allowance, pick out

videos, etc):

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Personal Possessions

Important items for my (our) relative to have at his/her home: (i.e. collections, TV/VCR, stereo,

etc.)

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Personal Care

My (our) relative appreciates assistance with the following personal care tasks: ______

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My (our) relative is able to do the following personal care tasks alone: ______

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My relative is used to the following personal care items (i.e. brands of shampoo, soap,

toothpaste, razor, etc.): ______

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My (our) relative is used to the following personal care routine: ______

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Height: ______Weight: ______Clothing Size: ______Shoe Size: ______

Describe how you best reinforce your relative’s self-esteem: ______

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Food and Eating

My (our) relative is able to do the following food preparation and clean up: ______

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Assistance needed: ______

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My (our) relative likes the following foods: ______

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My (our) relative dislikes the following foods: ______

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Special information regarding food and my (our) relative: ______

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Family customs regarding food: ______

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Section Three: Goal and Our ‘To Do’ List

Goal: Our relative’s desired future living arrangement:

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Our ‘To Do’ List:

Specify the actions you should take to achieve this goal.

1. ______

2. ______

3. ______

4. ______

5. ______

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Section Four: Postsecondary Education, Work, and Retirement

Current education, work, or retirement activities (include organization name and contact person):

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Desired activity: ______

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Important information regarding future plan: ______

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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.

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Activities my (our) relative does not like: ______

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Unstructured activities (collections,

music, TV shows, interests)

Special things to know

Vacations (past ones and future dreams): ______

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Fitness Program or Health Club: ______

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Voting: ______Absentee ballot ______In person ______

Library member: ______If YES, specify branch and location:

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Clubs: ______

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Religious or spiritual needs

Current religious institution affiliation (name, address and phone): ______

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How has individual participated in religious community? ______

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What aspects of religion/spirituality are important?______

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Funeral Arrangements (burial, cremation, cemetery plot, financial plan, type of service):

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Section Four: Goal and Our ‘To Do’ List

Goal: Our relative’s postsecondary education, work, or retirement:

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Our ‘To Do’ List:

Specify the actions you should take to achieve this goal.

1. ______

2. ______

3. ______

4. ______

5. ______

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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)

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Our Relative’s Medical Care:

Diagnosis: ______

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Current Doctors Address Phone Experience with Doctor andRoutine of Care

Medications:

Name of Medication Dosage What is it for? Prescribed by?

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Doctors not to go to (Explain why): ______

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Medical services and therapies: ______

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Dentist: ______

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Allergies: ______

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Ophthalmologist and Audiologist: ______

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Important information regarding vision, hearing, devices, or special equipment: ______

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Important information regarding seizures: ______

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Past operations / conditions: ______

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Sleeping habits: ______

Other important medical information (Genetic testing, immunizations, birth control):

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Education history of family member with disability

School Name Dates Comments

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My (our) relative has a current Individual Education Plan (IEP):

Yes _____ No _____ Not Applicable ______

Important information about the IEP: ______

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My (our) relative currently has a transition plan:

Yes ____ No _____ Not Applicable ______

Important information regarding the transition plan: ______

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What are the future educational needs of my adult relative with a disability? ______

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Why is this important to the family member with a disability? ______

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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: ______

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What to spend it on? How often? How much?

The Trustee of his/her trust is (Name, address, and phone): ______

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The Advisor of the trust is (Name, address, and phone): ______

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Guardian (Name, address, and phone): ______

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Successor Guardian: ______

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Power of Attorney: ______

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Successor Power of Attorney: ______

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My (our) relative has a will? Yes ____ No ____Where is it located? ______

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My (our) relative has an advance directive for healthcare? Yes ____ No ____

Describe: ______

Financial Information

Representative Payee (Name, address and phone): ______

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Receives SSI ____ Current Amount: ______Medicaid Number: ______

Receives SSDI ____ Current Amount: ______Medicare Number: ______

Other income or assistance: ______

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Banking

Bank/Credit Union Name: ______

Address: ______

Contact person and phone: ______

Savings Account Number: ______

Checking Account Number: ______

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Paychecks

Amount of paychecks: ______

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Uses paychecks for: ______

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Does own banking: Yes _____ No ____

Specific assistance needed: ______

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Tax Information

Accountant Name: ______

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Can do own taxes: Yes ____ No ____

Specific assistance needed: ______

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Section Five: Goal and Our ‘To Do’ List

Goal: Designate a Successor Caregiver:

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Our ‘To Do’ List:

Specify the actions you should take to achieve this goal.

1. ______

2. ______

3. ______

4. ______

5. ______

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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:

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Goal Priority 2:

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Goal Priority 3:

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Goal Priority 4:

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Goal Priority 5:

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Other Information

Other information that you would like to add about your relative:

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