Month 2 Letter of intent
Let's continue to work on a family letter of intent
Medical History and Care
Diagnoses: List main diagnoses for you child
Seizures: indicate seizure history, whether currently controlled, for how long, any known “triggers”
Functional skill level: what activities they perform, how independent, any required assistive devices.
Vision: status of child’s vision, do they need glasses, list date of last eye exam, and copy of any RX for eyewear.
Hearing: status of hearing, and any adaptive equipment needed, list date of last hearing test.
Speech: status of speech, do they use any communication aids, how easily do strangers understand, If non-verbal specify techniques you use to communicate. If you are not around who is the next best person that understands your child’s speech.
Mobility: indicate level of mobility, any required assistance or equipment necessary.
Blood: list your child's blood type and any special problems concerning blood.
Insurance: List type, amount, and policy number for medical coverage, what is included in the coverage, will the death of parents have any effect. Don’t forget to include Medicare and Medicaid information also.
Current Physicians: list current physician, including specialist. Full name, type of practice, address, phone numbers, average number of visits a year, the total charges from each doctor during the last year, and the amounts not covered by insurance.
Previous Physicians: full names, address, phone numbers, type of practice, most common reasons they saw your child, describe any important findings or treatment. Explain why you are no longer using them.
Dentist: Full name, address, phone number, frequency of exams, any recommendations or special treatment plan.
Nursing needs: indicate any need for nursing care, list reasons, procedures, nursing skill required, and typical location of care (home, office etc.)
Mental Health: Provide details of any Psychiatrist, Psychologist, Counselor, frequency of visits, and treatment plan.
Therapy: Provide details of any Speech, Occupational, or physical therapy your child receives, include therapist name, address, phone and location of service. Does your child need any modifications to the home, or assistive devices to make environment more accessible.
Diagnostic Testing: list information about all diagnostic testing in the past: Name of individual or organization that administered, address, phone number, testing dates and summary of findings. How often does testing need to be completed and where.
Genetic Testing: List findings of any genetic testing. Name of individual or organization who completed, address, phone number, and testing dates.
Immunizations: list type and dates of all immunizations
Diseases: List all childhood diseases and date of their occurrence. List any other infectious diseases your child has had in the past, any current, any diagnoses as a carrier for any disease.
Allergies: List all allergies and current treatment. Include any past that they may have outgrown. Describe past and current treatments and their effectiveness.
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Springdale, AR 72762
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ChSNC®| CFP®