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:

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 routine, 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: