Fillable Printable Letter Of Intent Partnership Template
Fillable Printable Letter Of Intent Partnership Template
Letter Of Intent Partnership Template
Letter of Intent
Template
Date written/revised:
Address the letter to whomever you wish:
General Information
Full name of child:
Are there any other names you or your child have used throughout his or her lifetime
under which your child’s information may be listed or records might be kept?
Current address and phone number:
Child’s former addresses and phone numbers:
Date of birth:
Social security number:
Diagnosis of Individual with Disability:
Family Social Security Numbers:
Mother:
Father:
Siblings (if needed):
Two people who know the most information about the child:
1. Name, address and phone number
2. Name, address and phone number
Miscellaneous Information
Stepparents (current or previous):
Former Spouses:
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Citizenship Status (if other than US born citizen):
Professional Contacts
Attorney/Trustee
Name, address and phone number:
Clergy
Name, address and phone number:
School (if applicable)
Name, address and phone number:
Employer (if applicable)
Name, address and phone number:
Financial Planner
Name, address and phone number:
Insurance Agent
Name, address and phone number:
Primary Care Physician
Name, address and phone number:
Other Therapists and Doctors
Name, address and phone number:
Pharmacy
Name, address and phone number:
Mental Health Professional
Name, address and phone number:
Waiver Contacts (if applicable
Name, address and phone number:
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Resource Coordinator, Agency
Name, address and phone number:
Respite Providers
Name, address and phone number:
Current Lifestyle and Expected Changes
Typical daily routine (include weekdays and weekends)
Activities/Interests:
Does he/she attend a church? Religious Affiliation?
Anticipated changes in the next two years:
What activity does your child particularly like or dislike? Consider recreation, sports and
fitness activities. Think also about other likes and dislikes (food, hobbies etc.).
Favorite places to visit in the community where people are familiar:
Who are your child’s friends and their parents (include contact information)?
How does your child react during stressful times? Are there certain things that someone
should know about helping your child through particularly stressful times or transitions in
your child’s life? Is there a particular person who can provide comfort in an emergency
(clergy, friend)?
Special supports and services currently receiving:
Who provides them, how are they paid?
Have you applied for special supports and programs including public benefits?
Are you currently on a waiting list for any service? Include the name of the service,
contact person, phone number, date and status of application.
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Who in your community might be interested in spending time with your child, i.e. going
to community events or activities and how can they be reached?
The future
Describe your idea of what life would look like for your child in the future.
What things are most important to you?
Where would he/she live?
What would he/she do during the day?
What type of help or support would you envision?
What types of activities would he/she enjoy most?
What types of employment/volunteer work would you suggest be explored?
Identify friends/relatives who may be able to play a role in your child’s life (make sure
you also discuss this with those individuals and your child). Include contact information.
Identify any people, including relatives, who you would NOT want to play a role in your
child’s life.
Provide the name of the person (and alternates if possible) who you prefer to be a primary
advocate and a friend for your child.
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If your child is expected to receive day, residential or other supports from an agency, are
there any particular providers or other non-health care professionals you would like to be
considered? Include contact information and dates of applications.
What are the three most important things you would want someone to consider when
planning for your child’s future?
What are three of the most important things you want your child to know about your
planning?
Legal and financial
Do you have a will – where is it located?
Do you have a Supplemental Special Needs trust? Who is the trustee, and where can the
document be found? (include contact information)
If you envision your child living in the family home, what arrangements have been made
regarding that home (ownership, title, etc) and where can those documents be found?
What financial arrangements have you made to provide funds for maintenance and other
upkeep on the home, while considering the effect on your child’s eligibility for public
benefits?
If your child is under 18 years old, list your first and second choice for legal guardian
with contact information.
If your child is an adult, who currently consents to medical care?
If your child consents to medical care, does he/she need some assistance with decisions?
If so, who would you suggest to provide this assistance? If you currently provide consent
to medical care (either formally or informally) who would you suggest assume this role?
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Have you made any funeral arrangements for your child? Do you have any special
wishes? Describe.
If your child is under 18 years old, who would be your choices to help manage your
child’s money or public benefits? Who would be your second choice? Contact
information.
If your child is over 18 years old, how does he/she handle his finances at this time?
What assistance does he/she receive?
Who would be your first choice to provide this assistance?
Who would be your second choice?
If there is already a representative payee (financial representative) list their contact
information.
List all bank accounts and other financial resources titled in your child’s name, or held on
your child’s behalf:
names and addresses of financial institutions:
type of accounts:
all owners on the account:
approximate amount in account:
List any life insurance policies that name your child (or a trust established for your child)
as either the beneficiary or insured. Provide the name of the company, status of your
child (owner, beneficiary, other) and contact information, and amount of insurance.
Does your child receive Social Security Supplemental Security Income (SSI) or other
cash benefits? If so, list type and amount.
Does your child have a representative payee for any of these benefits? If so, which
benefits? List contact information for each representative payee. If you are
representative payee, do you have a preference as to the person who would be designated
if you were unable to serve? Provide contact information.
If your child has been employed, where has he/she worked?
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What type of medical insurance does your child have? List all types, companies and
policy numbers, including private insurance, Medicaid and Medicare.
Records
List any schools your child attended:
Location of birth certificate, social security card, etc:
Attach any relevant evaluations that clarify their disability and needs:
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