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Questionnaire

Please take a few moments to complete this brief questionnaire. Your responses will help us identify your loved one's needs more effectively.

YES NO
	Do you have an up-to-date Last Will and Testament?
	Have you made arrangements to leave funds for your disabled family member in the event of your death?
	Have you thought about establishing a Supplemental Needs Trust for the benefit of your loved one?
	Have you and/or your loved one with a disability signed a Health Care Proxy?
	Have you talked with family members about being involved in the permanent care of your loved one with a disability?
	Have you appointed a legal guardian for your loved one? If so, have you appointed a standby guardian?
	Have you considered who in your life would be a trusted caregiver if you were no longer able to care for your loved one?
	Would you know what to do if your loved one’s benefits were threatened by too many assets?
	Have you made future living arrangements for your loved one in the event that you are unable to care for him/her, either short term or permanently?
	Could your loved one with a disability handle his/her own money, if you weren’t able to help?
	Have you documented your loved one’s history, hopes and dreams so that you can pass your knowledge on to future caregivers?
	Have you talked to your loved one with a disability and your family about what your wishes are for his/her future?

If you answered NO to one or more of these planning questions, talk to your Service Coordinator about your concerns or call Doris Green at Future Care Planning Services
585-402-7840