Planning Ahead - Florida Developmental Disabilities Council

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Life AreaThinking / UnderstandingNormal Normal with GlassesSeeing / VisionImpairedLegally BlindLast Eye Exam:Frequency Required:NormalNormal with hearingaidHearingHypersensitiveImpairedDeafNormal Uses sign languageSpeechUses CommunicationImpairedDeviceNormalWheelchairSpecial ShoesImpairedMobilityUses Walker Uses Artificial LimbUses other Orthopedic devices (List):Help NeededPeriodic health screenings are an important way to stay healthy. Indicate the most current medicalexaminations.MammogramVision CheckExamination Date Examination DateGynecological exam, PapsmearHearing CheckProstateDental CheckupBlood Pressure CheckAnnual Physical CheckupGlaucoma (familyhistory)A doctor has recommended that the person have the following special checkups regularly:Prescribed by:WhereAdministeredFor What Problem Frequency Required DurationFrequency of bowel movement:Problems with constipation: YES NO Remedy:Problems with Urination:Urinary Infections Frequent Urination Bladder Leakage (Frequency):74 Section 2, The Personal Information Section
PROTECTING LEGAL RIGHTS AND FINANCIAL STATUSThis section describes the financial arrangements that have been made to benefit the person andprotect legal rights. Be sure that the names of any financial advisors are included as well as copiesof court orders or other legal papers.Person needs assistance with:Banking Paying Bills Making Purchases Counting Money Recognizing Denominations of MoneyFinancial Safeguards:Two Signature Checking Accounts Representative Payee A TrustOther (Describe):Name of Trust:This trust is: Revocable Special Needs IrrevocableTRUSTEES NAME(S) ADDRESS(ES) PHONE NUMBER(S)CurrentSuccessorsCopy of the trust can be found:POWER OF ATTORNEYHas power of attorney been given to anyone: Yes No Limited DurableIf Yes, Name:Phone Number:Address:REPRESENTATIVE PAYEEDoes a representative payee receive benefits for the person? Yes NoName:Phone Number:Address:Does the person receive? Yes/No Amount Per MonthA pension / retirement income?Trust incomeSocial Security benefitsSupplemental Security incomeOther benefits / income (specify):Section 2, The Personal Information Section75
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AcknowledgementsWe would like to th
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SECTION 1THE HANDBOOKDevelopmental
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in realizing goals and outcomes he
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• Identify agencies and organizat
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TO BE SURE YOU HAVE ACCESSED ALL AV
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CHAPTER THREEUsing Government Benef
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Property or assets mean real estate
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There is a special program for peop
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Department of Elder Affairs: The De
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Be sure to complete the application
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Most services provided to persons w
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CHAPTER FIVEAdvocating and Coordina
Page 30 and 31: family member receives services. De
Page 32 and 33: • Use the chain of command. If yo
Page 34 and 35: 28ChooseYour family member may make
Page 36 and 37: 7. Skilled Nursing HomeSkilled nurs
Page 38 and 39: There are now more opportunities fo
Page 40 and 41: If your family member really thinks
Page 42 and 43: pre-need directive. As the term ind
Page 44 and 45: Can the Living Will and the Health
Page 46 and 47: Although it is not required by stat
Page 48 and 49: The potential ward, if capable of u
Page 50 and 51: LETTERS OF INTENTIn addition to hav
Page 52 and 53: TAX ISSUESIn your planning, do not
Page 54 and 55: CHAPTER TENDealing WithHealth Care
Page 56 and 57: CHAPTER ELEVENCoping with Changes a
Page 58 and 59: • Arrange visits to an area funer
Page 61 and 62: SECTION 2THE PERSONALINFORMATION SU
Page 63 and 64: Senior CenterHomemakerPersonal Care
Page 65 and 66: List relatives who are emotionally
Page 67 and 68: Recognizes danger of: (Circle those
Page 69 and 70: Do violent or sexually suggestive T
Page 71 and 72: The type of neighborhood preferred
Page 73 and 74: During the day goes to:EMPLOYMENT/R
Page 75 and 76: Provide a brief summary of Medical
Page 77 and 78: Section 2, The Personal Information
Page 79: The following activity (e.g., being
Page 83 and 84: Has a standby guardian been appoint
Page 85 and 86: Memorial Service: Yes No Location:S
Page 89 and 90: SECTION 3HELPFUL ATTACHMENTSDevelop
Page 91 and 92: Additional Instructions (optional):
Page 93 and 94: My Personal OutcomesWHO AM I?What g
Page 95 and 96: Bill Of RightsIn June of 1975 the G
Page 97 and 98: Stakeholders requested a change in
Page 99 and 100: Adjudicatory hearing to determinein
Page 101 and 102: Guardianship To-Do List(Step-by-Ste
Page 103: New York State Developmental Disabi
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Planning Ahead - Florida Developmental Disabilities Council

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