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Return to the Services & Supports Section- Step One

Now & Future Needs Checklist
NOTE: The following list is meant to merely be a guide to those life areas where people with developmental disabilities commonly need some assistance. Since every individual is different, please add additional details that are appropriate for your loved ones' needs.

Daily Living Tasks

Personal care (toileting, dressing, grooming, eating, etc.)
Describe help needed:

Household (shopping, meal preparation, paying bills, etc.)
Describe help needed:

Safety (dialing 911, using locks & keys, emergency actions)
Describe help needed:

Supervision (behavior, knows daily routine, etc.)
Describe help needed:

Transportation (takes a bus, needs a ride to work, etc.)
Describe help needed:

 

Now

 




 


 

 


 

 

Future

 




 


 

 


 

 

Health Care Tasks

Routine health care visits (make and attend doctor/dental appointments; follow up)
Describe help needed:

Follows instructions (takes medications, brushes teeth, etc.)
Describe help needed:

Healthy lifestyle (balanced diet, regular exercise, etc.)
Describe help needed:

 

 


 

 



 

 

 

 


 

 



 

 

 

Work & Leisure Tasks

Daily (job or scheduled program, leisure activities)
Describe help needed:

Social/religious (specific community, has friends)
Describe help needed:

Volunteers (attends as desired; group member, etc.)
Describe help needed:

 

 


 

 



 

 

 

 


 

 



 

 

 

Legal & Financial Tasks

Legal rights (has guardian/guardian advocate; acts on own behalf)
Describe help needed:

Civil rights (can vote, able to marry, understands laws, etc.)
Describe help needed:

Informed consent (can understand risks, benefits, alternatives for a medical procedure or treatment)
Describe help needed:

Making purchases (knows appropriate costs; can make change, write checks)
Describe help needed:

Signing contracts (can understand terms, conditions, restrictions)
Describe help needed:

Beneficiary of a Trust Fund (special needs trust)
Describe help needed:

My relative needs supports in these other areas of life: (please be specific)

 

 


 

 



 

 


 

 

 

 

 

 

 

 

 

 


 

 

 


 

 



 

 


 

 

 

 

 

 

 

 

 

 

 

[Remember, your loved one must first be a client of the Developmental Disabilities Program. If this has not already been done, call and do it now!]

Name of individual:

Social Security #:

Medicaid #:

Support Coordinator:

Phone Number:

Guardian/Guardian Advocate:

Phone Number:

Add any details unique to your relative's needs- communication difficulties, important preferences (food, clothing, music, etc.), hope & dreams, etc.: