"Essential Lifestyle Plan (Elp) Workbook" - Delaware

This "Essential Lifestyle Plan (Elp) Workbook" is a part of the paperwork released by the Delaware Health and Social Services specifically for Delaware residents.

The latest fillable version of the document was released on September 10, 2007 and can be downloaded through the link below or found through the department's forms library.

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Download "Essential Lifestyle Plan (Elp) Workbook" - Delaware

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Revised 9/10/07
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
_______________________________
Revised 9/10/07
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
_______________________________
Revised 9/10/07
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
Revised 9/10/07
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)
Revised 9/10/07
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? ____________________________
Revised 9/10/07
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: _____________________________________
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