By completing the information below, you are agreeing to act as a Family to Family resource for other families of people with special needs in Kentucky. The information that you provide in the starred areas below (*) will be published in the Family to Family database and Family Resource Directory. You have the option to accept phone calls or emails from families of people with special needs. You also have the option to share your personal knowledge and experience in the areas you check.

Please print and return completed forms to:

The Arc of Kentucky
Family to Family Health Information and Education Initiative
706 East Main Street, Ste A
Frankfort, KY 40601


email: TheArcofKy@arcofky.org
Phone: 1-800-281-1271 or 502-875-5225

PLEASE PRINT

*Name:_____________________________________*Email:_____________________________________

Address:_____________________________________*City:___________________________State:______Zip:_______

*Phone #:____________________________________*Language(s) spoken:____________________________________

 

*Preferred time to be contacted by phone: ______________Day ______________Evening ____No preference

Family members special need, birth date and gender (if you have more than one family member with special needs, please list each one separately):

Special Needs
*Birth Date
*Gender
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

*Do you belong to any groups or organizations or participate in any activities that relate to people with special needs and their families? If so, please list:
______________________________________________________________________________________________

______________________________________________________________________________________________

Please check those that apply:

_______I am willing to have other families contact me by phone and permit Kentucky Family to Family to publish my phone number for this purpose.

_______I am willing to have other families to contact me by email and permit Kentucky Family to Family to publish my email address for this purpose.

How did you hear about Family to Family? _____________________________________________________________

Signature_______________________________________________ Date____________________________________
Note: You can retract or update this information at any time by calling or emailing The Arc orf Kentucky Family to Family Health Information and Education Initiative.

 

(Do not feel that you need to be an EXPERT to check an area -- just that you have some experience. Views families share with each other will be based on personal life experience and should not substitite for the advice of qualified professionals.) I/We have some experience in the areas checked below and would welcome the chance to share those experiences with other families.

 

HEALTH CARE - (including behavioral health)
___ Diet and nutrition interventions ___ Hygiene, grooming, self-dressing
___ Navigating SSI/Medicaid system ___ Sexuality and/or Social skills
___ Challenges of caring for medically fragile person ___ Grieving and loss
___ Accessing/mamaging/supervising in-home supports ___ Accessing specialty clinics
___ Acquiring durable medical equipment (including diapers) ___ Primary care physicians familiar with disabilities
___ Positive behavior support with disabilities ___ Hospital stays
___ Issues of multiple disability ___ health Policies/Insurance
___ Accessing dental care  
___ Feeding problems  
   
TECHNOLOGY
TRANSPORTATION
___ Augmentative communication ___ Public transit
___ Assistive technology for learning ___ Specialized vans
___ Low tech devices ___ Air travel (accessibility, metal detectors)
 
COMMUNITY INCLUSION
___ Child care ___ Community safety (e.g. police)
___ After school care ID registration, home safety tips ___ Taking family vacations
___ Inclusion in community recreational actiities ___ Inclusion in faith communities
  ___ for children   ___ Support groups
  ___ for teens   ___ For person with disability
    ___ For family members
 
EMPLOYMENT AND ADULT SUPPORTS
___ Accessing meaningful employment in the community ___ Understanding the adult DD

___ Working with the Office of Rehabilitation Services system

 ___ Person directed funding
___ Creative-housing supports for adults with disabilities ___ Living independently
 
PLANNING FOR THE FUTURE
___ Alternatives to guardianship ___ Self-determination
___ Special needs estate planning (wills, trust, etc.) ___ Supported decision-making
___ Person-centered planning  
 
OTHER AREA(S) NOT LISTED ABOVE (please specify)
_________________________________________________________________________________________
_________________________________________________________________________________________