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LIFE CARE PLAN
For __________________
Written by ________________
Date_______________
475 Half Day Road, Suite 100, Lincolnshire, Illinois 60069PHONE: 847-793-2484 • FAX: 847-793-2485 • WEB: www.rivkinlaw.com
EMAIL: [email protected][A Microsoft Word version of this document is available at http://LCP.rivkinlaw.com]
PERSONALFull Legal NameOther Names Known By (including maiden name, if applicable)Date of Birth
Place of Birth and Hospital
Father’s Full Name
Mother’s Full Name
Step-parent Full Name
Step-parent Full Name
Name(s) and Age(s) of Sibling(s)
Name(s) and Age(s) of Children
Languages Spoken/UnderstoodSocial Security Number and Location of CardCitizenship and Location of Immigration Records, if anyPassport Number and Location of PassportDriver’s License Number, State of Issuance, and Location of LicenseOrgan Donor Indicated on Driver’s License?Current County and State of ResidencyYear Residency Established
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CURRENT MEDICAL STATUS AND ADAPTIVE SKILLSDiagnosisGeneral Overall Functioning (high/low, level of independence, awareness)Seizures?
Cognitive Functioning
Vision
HearingSpeech Skills (verbal/nonverbal; intelligibility to an unfamiliar listener)Use of Augmentative Communication Device/Sign Language?Literacy Level
Writing/Typing Skills
MobilityAllergies (food, medication, environmental, etc.) and SymptomsBlood Type
Mental HealthHealth Providers to be Avoided and Why (provide name and type of provider)
MEDICAL HISTORYDiagnosis
Other Significant Illnesses
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MEDICAL HISTORYImmunizations
Seizures
Operations
Hospitalizations
Genetic TestingRecent Diagnostic Testing (date, location, title of evaluator(s), summary of results)Evaluation of Intelligence (date, location, title of evaluator(s), summary of results)
ROUTINE CARECurrent Height and Weight
Current Clothing and Shoe Sizes
General Diet
Favorite Foods
Lease Favorite FoodsMedication – Prescription (name and when taken)Medication – Over the Counter (name and when taken)How Medication is Monitored
How Medication is Procured
Toileting Needs
Birth Control
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ROUTINE CAREPersonal Hygiene (if female, address feminine care issues)Devices
Therapy
Ongoing ProceduresEye Glasses, Contacts, Hearing Device, Other Special Equipment
BEHAVIORSTypical Temperament
Best Way to be Comforted
Best Way to be Motivated
Best Way to PraiseEnvironment/Things/Activities That Result in Positive BehaviorsEnvironment/Things/Activities That Result in Challenging BehaviorsSpecific Inappropriate Behaviors/ChallengesBest Way to Manage Inappropriate Behaviors/ ChallengesBehaviors/Symptoms That May Indicate a Change in Medication and/or Surrounding May Need to Be AddressedFears and Best Way to Manage Them
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BEHAVIORSBest Way to Deal with Change (i.e. school, programs, living, family, therapies, etc.)
DAILY LIVING SKILLSDaily Routines or Rituals – Accomplish AloneDaily Routines or Rituals – Accomplish With AssistanceSleep Habits
Most Effective Caregiver ApproachManagement of Personal Finances (do own banking, make change, understand value of money, receives allowance, etc.)Household Tasks (accomplish alone, accomplish with assistance, hope to accomplish in the future)Traveling Abilities (take the bus or train alone or assisted, walk alone or assisted, airplane travel, etc.)
EDUCATIONSchool(s) (current and prior)IEP/IPP/Transition Plan Summary (include current programs, academics, emphasis/goals, and integration; attach as applicable)Favorite Classes/Activities
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EDUCATIONLease Favorite Classes/ActivitiesTherapies Received at School (type, name of provider, and schedule)Plans for College
DAY PROGRAM OR WORKCurrent
Past
Future Goals/Hopes
Tasks Completed Independently
Tasks Requiring Assistance
Type of Work/Program Enjoy Most
Type of Work/Program Enjoy Least
LEISURE AND RECREATIONStructured Recreation
Unstructured Activities
Vacations
Fitness
Favorite Restaurants
Favorite Stores
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LEISURE AND RECREATIONFavorite BooksFavorite TV Shows, Movies, Websites, Computer GamesActivities and Destinations to be Avoided
HOUSINGPresent
Past
Future Placement Choice(s)Considerations for Future Placement (size preference, group home, CILA, city, suburb, same sex, etc.)Required Adaptations (ramps, no stairs, etc.)Community Integration
Transportation Requirements
HEALTH CARE PROVIDERS (also list prior providers, if believe the information may be helpful in the future)Type of Provider (general
practitioner, specialist, dental, vision, therapist, mental health, dietician,
home health care aide etc.)
Contact Information and Hospital Affiliation Medications Prescribed Notes
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HEALTH CARE PROVIDERS (also list prior providers, if believe the information may be helpful in the future)Type of Provider (general
practitioner, specialist, dental, vision, therapist, mental health, dietician,
home health care aide etc.)
Contact Information and Hospital Affiliation Medications Prescribed Notes
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GUARDIAN, HEALTH CARE AND PROPERTY AGENT, REPRESENTATIVE PAYEEType of Fiduciary (Guardian, health care agent, property agent, representative payee etc.)Indicate if current or future
Name, Address, E-mail Address, Mailing Address, Home Phone Number, Work Phone Number, Cell Phone Number
Notes and Specific Information (state/county of guardianship, successor guardians, etc.)
RELIGIONFaith
Clergy Contact Information
Participation
RIGHTS AND VALUESImportant Family ValuesRights to be Kept if at All Possible (marriage, voting, reproductive, etc.)
IMPORTANT RELATIVES AND FRIENDSName and Relationship Contact Information Notes
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IMPORTANT RELATIVES AND FRIENDSName and Relationship Contact Information Notes
PET
Type of Pet and Name Veterinarian Contact Information Medications Pet Insurance Information
COMPUTER/TABLET/SMARTPHONEType of Device (tablet, laptop,
desktop, Kindle, smartphone, etc.) Location User Name and Password Automatic Renewal of Software Licenses
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COMPUTER/TABLET/SMARTPHONEType of Device (tablet, laptop,
desktop, Kindle, smartphone, etc.) Location User Name and Password Automatic Renewal of Software Licenses
E-MAIL, SOCIAL MEDIA, DIGITAL STORAGE, AND OTHER SIMILAR ACCOUNTSType of Account (E-Mail, Facebook, Twitter, iCloud, Dropbox, Shutterfly,
Blogs, Domain Names, PayPal, eBay, Craig’s List, etc.)
Website/E-mail Address/HostUser Name, Password, and
Description of What the Account is Used For
Notes
FREQUENT FLYER AND OTHER AWARD PROGRAMS
Type of Program (airline, hotel, car, credit card, Upromise, etc.) Vendor Name Contact Information
Account Number and Online Information (website, user name,
password, etc.)Other Information
ADVISORType of Advisor (accountant,
insurance agent, attorney, investment advisor, banker)
Firm Name and Contact Person Firm Address, Phone, Website, and E-mail
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ADVISORType of Advisor (accountant,
insurance agent, attorney, investment advisor, banker)
Firm Name and Contact Person Firm Address, Phone, Website, and E-mail
INCOME
Type (Employment, SSI, SSDI, SSA, Other)
Contact Information (if online access, include website, username
and password)Monthly Amount Notes
INSURANCE POLICYType of Insurance (Medicare,
Medicaid, health/dental/vision auto, homeowner’s/umbrella/flood, life,
long-term care, etc.)
Insurance Carrier and Contact Person
Insured Name(s), Policy Number, Amount of Coverage, and Premium
Payment InformationNotes
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IMPORTANT DOCUMENTSContact Information (for attorney, accountant, benefits planner, etc.,
if applicable)
Where Original Documents (or copies) are Stored Date of Last Update
Birth Certificate
Marriage Certificate N/A
Prior Divorce Documentation
Pre-Marital Agreement
Health Care Power of Attorney
Property Power of Attorney
WillRevocable Trust (i.e. Declaration of Trust)Supplemental/Special Needs Trust (s)Other Trusts
Guardianship Documentation
Medicaid/SSI Application/Ongoing Reports
Income Tax Returns
LIABILITYType of Debt (home, auto, college,
credit card, etc.) Lender Contact Information Loan Number and Name(s) of Borrower(s) Terms of Loan and Payment Information
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LIABILITYType of Debt (home, auto, college,
credit card, etc.) Lender Contact Information Loan Number and Name(s) of Borrower(s) Terms of Loan and Payment Information
REAL ESTATE (PERSONAL RESIDENCE)
Property Address and Keyholders PIN and Location of Deed Utility and Alarm Company Information
Service Companies (handyman, lawn, snow, cleaning, appliance, etc.)
FINANCIALType of Account (safe deposit box, checking account, savings/money
market account, CD account, investment, retirement, online
account)
Institution Name and Contact Information (if online access, include website, username and
password)
Account Title and Account NumberOther Information (i.e., location of safe deposit box keys, contents of box, CD maturity dates, bank register(s), etc.)
AUTOMake, Model, and Year VIN and License Plate Number
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CREDIT CARD
Type of Credit Card (American Express, MasterCard, Visa, store
specific, etc.)
Lender Name and Contact Information (if online access, include website, username and
password)
Account Holder Name(s) and Credit Card Number Payment Information
FUNERAL
Funeral Home Contact Information Burial/Cremation Contact Information Terms of Arrangements and Location of Documentation Notes
ADDITIONAL NOTES:
Date last updated:______________________________
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