1. Author of the Letter Full Name Relationship to Beneficiary Details of Relationship (e.g., how long known, nature of care) Purpose of Letter 2. Beneficiary Information Full Name (and nicknames) Date of Birth Phone Number Email Marital/Relationship Status SingleMarriedDivorcedLong-Term Partner Details 3. Living Situation Current Address Describe Individual’s Current Living Situation Length of Time at Current Residence Is this a stable environment? YesNo Do they enjoy it or want to move? Flight Risk? YesNo Your Preference for Their Housing If they live with you, what’s the future plan? How is housing currently funded? Additional Living Notes Next4. Education Highest Level Completed High SchoolGEDSome CollegeAssociate'sBachelor'sGraduate DegreeOther Still in School? YesNo Educational History and Preferences School(s) Attended (Names, Address, Contact Info) 5. Family Information Parents (include marital history) Siblings (include relationship and parents) Extended Family (Grandparents, Aunts, etc.) “Like Family” Individuals Religion or Belief System Important Holidays or Traditions Family Strengths and Challenges Problematic Family Situations or Members 6. Legal Information Legal Decision-Making SelfSupportedGuardian Guardian of the Person: Name, Contact, Attorney, Case # Guardian of the Estate: Name, Contact, Attorney, Case # Successor Guardians/Alternatives Exclusions or Special Requests BackNext7. Financial Information Responsible for Finances Is Beneficiary Financially Independent? YesNo Limits or Guidelines (e.g., $20 max cash) Bank Accounts & Access Property Ownership (Real/Personal) Vehicle Info (make/model/year/ownership) Representative Payee Info 8. Professionals Support Staff/Caseworker Teachers Family Attorney Medical Professionals Trustee/Financial Advisor Spiritual Advisors (names, roles, contact info) 9. Medical History Primary Diagnoses/Conditions Insurance (Medicaid, Medicare, Private) Primary Care Providers Daily Living Needs ShoweringDressingEatingToiletingTransferringMobilityShoppingFinancesCookingHousekeepingMedications Assistive Devices Used Mental Health History and Support Needs Therapies Received Dental History/Needs Dietary Needs End-of-Life Wishes (Living Will, DNR, etc.) BackNext10. Likes and Dislikes Likes (activities, food, etc.) Dislikes (triggers, food, etc.) Favorite Places or Vacations People They Enjoy Spending Time With Hobbies/Fun Activities Future Hopes/Goals 11. Daily & Seasonal Routines Daily Schedule (weekday/weekend) Seasonal Activities (e.g., beach in summer) 12. Employment or Volunteerism Current Job/Volunteer Site Job Coach or Support Services BackNext13. Religion Religious Affiliation Important Beliefs or Practices Clergy Contact Info Level of Participation 14. Emergencies Emergency Contact(s) How They React to Emergencies Support Strategies During Crisis 15. Final Arrangements Funeral Plans Made? YesNo Company/Contract Info Preferred Arrangements BurialCremation Location of Remains or Service Details Back
