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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]

http://lcp.rivkinlaw.com/

mailto:[email protected]

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

RIVKIN & RIVKIN, LLC – Life Care Plan Page 1

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


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


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


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


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


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


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


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


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


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


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


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


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


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:______________________________
