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Modern Estate Planning
Estate Plan Process
Estate Plan Options
Young Family Planning
Special Needs Planning
Elder Care Planning & Medi-Cal
Veterans Aid & Attendance
Ebooks & Guides
1. Person With Disability
Full Legal Name
Also Known As
Date of Birth
Telephone Number - Best phone for contact
Does the person expect to remain in the State where he or she is living currently?
If not, where might they move?
Has a legal guardian or conservator been appointed by a court for the person with disabilities?
Date of Appointment
2. Disability Information
Type/ Name of Disability
Age of Onset
Before age 18
Before age 22
Before age 26
Other (age of onset)
Can the person work?
If Yes, is the person currently employed?
Can the person drive?
Can the person live independently?
If not, please describe where they are living and projected duration of this arrangement.
3. Governmental Assistance / Public Benefits
(Please bring most recent award letter to the meeting)
What government programs is the person currently receiving assistance from?
Social Security Disability Income (SSDI)
Rental assistance/HUD (Section 8)
Supplemental Security Income (SSI)
Social Security Childhood Disability Benefits (CDB)
Other (government program)
If the person is not receiving Medi-Cal (Medicaid) or Medicare, how are their medical expenses being paid?
Did the person with disabilities receive any public aid or assistance before turning 18?
If so, what kind of assistance was received?
Is the person with disabilities a Regional Center client?
Local Office / Contact Name
What services are provided?
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