When you have completed this workbook, please return it to: Name of Family Support Specialist: _____________________ Office address: _______________________________________ _______________________________________ _______________________________________ _______________________________________ Phone number: _______________________________________ * If you received this form electronically (by email), you should print and return it by mail to the office address listed above. Personal information sent via email may not be secure. In order to protect your personal information, please DO NOT return this form by email. Essential Lifestyle Plan (ELP) Workbook For _______________________________ THINGS OTHER PEOPLE LIKE ABOUT ME: MUST HAVE: (These are things you have to have in order to have a good day. You can’t do without them.) MUST NOT HAVE: (These are things you cannot have or don’t want in your life. These would make you have a bad day). Important People: Name Relationship Address & Phone LIKES: (Things to consider are people, activities, hobbies, religion, foods, things, places, music, TV shows, etc…) DISLIKES: (Things to consider are people, activities, hobbies, religion, foods, things, places, music, TV shows, etc…) HOPES & DREAMS: (Things you have always wanted to do) (Someday I want to…..) THINGS TO TRY & LEARN: (New things I’d like to learn) SUPPORTS : General Note: At the age of 18, you become your own guardian, unless the Court has appointed a guardian for you. Who is your Guardian? Self Other If you have a Guardian, does your Guardian have guardianship of: Person Property Both Date of Court Order: _____________________________________ Name of Guardian: ______________________________________ Relationship: ___________________________________________ Address: ______________________________________________ ______________________________________________ Phone: _________________________________________________ Do you have a: Power of Attorney Yes No Custodian Yes No Surrogate Decision Maker Yes No Emergency Contact Person: Name: ________________________________________ Relationship: ___________________________________ Address: _______________________________________ _______________________________________ Phone: ________________________________________ Financial Can you handle your own money? Yes No Coins: Yes No Dollars Yes No If yes, up to what amount? ____________________________ Who is your Representative Payee? Self Other Name & Relationship: _____________________________________ ______________________________________ Financial Information: Amount SSI $ __________________ SSDI/OASDI $ __________________ VA Benefits $ __________________ Pension (company name: _________________) $ __________________ Wages $ __________________ Child Support $ __________________ Total $ __________________ Checking Account: Account Number: ________________________ Name of Bank: __________________________ Savings Account Account Number: ________________________ Name of Bank: __________________________ Certificates of Deposit (CD’s) Amount: _______________________________ Name of Bank: _________________________ Trust Fund Trustee Name: __________________________ Trustee Phone Number: ___________________ Name of financial institution: _________________ Life Insurance: Person Insured: ____________________________________ Policy Owner: ______________________________________ Insurance Company: _________________________________ Company Address: __________________________________ Policy Number: ____________________________________ Pre-paid Funeral Arrangements Yes No If yes, name of the Funeral Home? __________________________________________ Address of Funeral Home: ________________________________________________ ______________________________________________________________________ Phone number of Funeral Home: ___________________________________________ Burial Plan: ____________________________________________________________ Burial Plot Yes No Location: _____________________________________ At Home I live with Name: _____________________________________ Relationship: ________________________________ Address: ____________________________________ ____________________________________ Phone: ______________________________________ Do you have anyone coming into the home to help you? Yes No If yes, name of support person or agency: _____________________________________ Address: _______________________________________________________________ Phone: _________________________________________________________________ Chores/responsibilities/activities that I enjoy doing around the house _______________________________________________________ _______________________________________________________ _______________________________________________________ At school/work/day program Name of school/work/day program: _____________________________________ Contact Person: ____________________________________________________ Address: ___________________________________________________________ ___________________________________________________________ Phone: ____________________________________________________________ Hours_______________________ Things that I enjoy at school/work/day program ___________________________ __________________________________________________________________ Do you need to pack lunch? Yes No Is your lunch provided? Yes No Do you have a clothing restriction? Yes No What? ________________ Do you take money daily? Yes No How much? ____________ Do you have transportation? Yes No What are the arrangements/times? ___________________________________________ _______________________________________________________________________ Communication I communicate in the following ways: I talk I gesture I sign I write I use a picture book I use a communication device What type?____________________________ Who fixes it when it breaks? ______________________________________ Other Do you understand simple directions? Yes No If people want to communicate with me they should __________________________________________________________________ ___________________________________________________________ ___________________________________________________________ How people can tell I like something _________________________________________________________________ _________________________________________________________________ How people can tell I don’t like something _________________________________________________________________ _________________________________________________________________ Other important information about how I communicate __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ If you don’t use words to speak, please complete the following: In this situation: When I do this: It means: You should do this: Example: Anytime you ask me to do something Bite my hand I don’t want to do it Stop asking for now, and ask me later Eating I eat without any help Yes No I use fingers spoon fork knife Do you use special utensils? Yes No If yes what: _________________________________________________________ ___________________________________________________________________ I need all food finely cut Yes No I need meat cut Yes No I need my food mashed or pureed Yes No I drink by myself from a cup Yes No Special eating or feeding instructions: ____________________________________ ___________________________________________________________________ My favorite foods: ___________________________________________________ ___________________________________________________________________ Foods I don’t like: ____________________________________________________ ___________________________________________________________________ Getting Around Do you walk by yourself without help? Yes No If no, how do you get around? ___________________________________________ ____________________________________________________________________ Do you: Sit up alone Yes No Need assistance Stand alone Yes No Need assistance Climb stairs alone Yes No Need assistance Safety Do you need someone to be with you all the time? Yes No Can you use 911? Yes No Can you use the telephone in emergencies? Yes No Do you need protection from being taken advantage of? Yes No Please explain: _______________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Do you put non-food items in your mouth? Yes No Are you aware of hot/cold? Yes No Do you watch for cars when crossing the street? Yes No Would you walk off/leave with strangers? Yes No Do you need to hold hands? Yes No Moods & Behaviors Describe your general behavior: _________________________________________ ___________________________________________________________________ Describe how you act in the community (on shopping trips, in restaurants, etc…) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ Do you have any habits? ______________________________________________ __________________________________________________________________ Do you ever: Hurt yourself Hit others Hit objects Throw objects Scream Have temper tantrums Lie Shoplift What causes this to occur? ___________________________________________ _________________________________________________________________ _________________________________________________________________ Describe what happens________________________________________________ ___________________________________________________________________ ___________________________________________________________________ What should we do when this happens? (How do you want us to help you?) ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Describe how you react to: Changes in your environment____________________________________________ ____________________________________________________________________ ____________________________________________________________________ Changes in your routine ________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Disappointment _______________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Do you presently have, or have a history of any of the following: Currently In the Past How is this treated? Aggressive behavior (physical) Aggressive behavior (verbal) Substance Abuse Setting Fires Running Away Self-Injuring Sexual Misconduct Stealing/Theft Psychiatric Issues Other Health Medicaid #: ____________________________________ Managed Care Provider: _____________________________________ Medicare #: _____________________________________ Part A Part B Medicare Prescription Plan (Part D): __________________________________________ Blood Bank Yes No Other Insurance: ______________________________________________________ Do you have any allergies to: Drugs Yes No What: ____________________________________________________ ____________________________________________________ Describe Reaction: __________________________________________ __________________________________________________________ Foods Yes No What: ____________________________________________________ ____________________________________________________ Describe Reaction: __________________________________________ __________________________________________________________ Other Yes No What: ____________________________________________________ ____________________________________________________ Describe Reaction: __________________________________________ __________________________________________________________ Medical Diagnosis/Health Problems: ______________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Psychiatric Diagnosis: __________________________________________________ ____________________________________________________________________ Name Address Phone How often seen? Family Doctor: Psychiatrist: Dentist: Other Doctors: 1.____________________ 2.____________________ 3.____________________ 4.____________________ Medication: I take medicine myself I need help taking my medicine Please tell us about ALL the medicines you are taking including prescription and non- prescription. For example, aspirin or suppositories, as well as dietary supplements such as vitamins. Medication: ______________________________________________ Prescription Non-prescription Reason Given: ____________________________________________ How do you take it: ________________________________________ Medication: ______________________________________________ Prescription Non-prescription Reason Given: ____________________________________________ How do you take it: ________________________________________ Medication: ______________________________________________ Prescription Non-prescription Reason Given: ____________________________________________ How do you take it: ________________________________________ Medication: ______________________________________________ Prescription Non-prescription Reason Given: ____________________________________________ How do you take it: ________________________________________ Medication: ______________________________________________ Prescription Non-prescription Reason Given: ____________________________________________ How do you take it: ________________________________________ Do you have seizures? Yes No Describe them: ________________________________________________________ _____________________________________________________________________ How often do you have seizures? __________________________________________ How long do they last? __________________________________________________ What happens after a seizure? _____________________________________________ What should we do when you have a seizure? ________________________________ _____________________________________________________________________ Do you use or need any physical health aids? None Dentures Glasses Hearing Aid Power Wheelchair Manual Wheelchair Walker Cane Crutches Support Crutches Hospital Bed Vail Bed Personal Care Are you: Independent (can do it by yourself) Dependent (need someone to physically help you will all the steps) Or do you need: Verbal prompts (someone to talk you through the steps) Physical assistance (someone to physically help you with some of the steps) In the following areas: Dressing: undergarments_____ shirt_____ pants _____ socks_____ shoes _____ coat ______ Special dressing instructions: ______________________________________________ ______________________________________________________________________ Bathing: bath tub _____ shower _____ washing hair _____ sponge bath _____ hair grooming _____ I can regulate my own bath water temperature Yes No Special bathing instructions: _______________________________________________ ______________________________________________________________________ How often do you like to bathe? ____________________________________________ Do you bathe in the morning? Yes No Do you bathe in the evening? Yes No Do you undress in the bathroom? Yes No Where do you dress for bed? _______________________________________________ Things I need to get a good night’s sleep: ______________________________________ ________________________________________________________________________ Do you use deodorant? Yes No Do you need help to apply it? Yes No Do you need help brushing your teeth? Yes No For Women: How often do you have a period? ______________________________ I use: a pad with belt tampons stick-on pad Do you need help with your period? Yes No Describe help needed: ______________________________________________ ________________________________________________________________ For Men and Women: I like to shave Yes No I prefer not to shave Yes No Electric razor Yes No Disposable razor Yes No Do you need help? Yes No If yes, how________________________________________________________ _________________________________________________________________ Do you: Use the bathroom without any help? Yes No If no, what help is needed: ____________________________________________ __________________________________________________________________ __________________________________________________________________ Sign to use the bathroom? Yes No Wear disposable undergarments? 1. During the day Yes No 2. At night Yes No 3. Both Yes No Need reminders to use the bathroom? Yes No Do you have a schedule? Yes No Please list: __________________________________________________________ Any special bowel care? Yes No If yes, please list: _____________________________________________________ ____________________________________________________________________