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Letter of Intent
A private guide for future care and support
Complete this blank worksheet on paper with the person whose life it describes, using their preferred communication and trusted supporters. Attach extra pages as needed. These spaces are for handwriting only; there is no online form, upload or saving of answers.
This guide records preferences and practical information. It is generally not legally binding and does not replace a will, trust, healthcare directive, power of attorney or guardianship order. Confirm legal arrangements with a qualified Kentucky attorney. It does not appoint anyone to a legal role or guarantee services.
Privacy: Keep the completed copy in a secure place. Share only what each authorized supporter needs. Do not include Social Security numbers, account numbers, passwords, access codes or copies of identification. Keep detailed medical, legal and financial records separately and note only how an authorized person can locate them. Do not send completed pages to Beyond Barriers.
The person and what matters
About me and my wishes
- Preferred name or initials; people who helped prepare this guide
- Strengths, interests, goals, values and cultural or spiritual preferences
- What a good day looks like; what I want future supporters to know
Communication and decision-making
- How I communicate, including AAC, gestures or other supports
- How I show agreement, discomfort, pain or a wish to stop
- How to offer choices and involve me; who helps me understand decisions
Complete privately on paper. Keep securely; do not return to Beyond Barriers. Attach additional pages if needed.
Letter of Intent
Everyday life and routines
Daily routines and practical support
- Morning, evening, sleep, meals and personal-care preferences
- Support needed with daily activities; helpful cues and approaches
- Transportation, equipment and accessibility needs; changes that are difficult
Relationships and community
- Important people, pets and relationships to maintain
- School, work, activities, faith, hobbies and community connections
- Preferred living arrangements and how I want to stay connected
Complete privately on paper. Keep securely; do not return to Beyond Barriers. Attach additional pages if needed.
Letter of Intent
Health, comfort and safety
Care preferences and current care plans
- Comfort, sensory preferences, appointment accommodations and ways to reduce distress
- Where authorized supporters can find current clinician-reviewed medication, allergy and care information
- Equipment training, maintenance and who to ask before changing care
Distress and emergency backup
- Usual baseline; changes that may mean pain, illness or distress
- Early warning signs, helpful responses and approaches to avoid; location of the current professional safety plan
- First backup caregiver and alternate if the usual caregiver is unavailable; first steps for a safe handoff
This worksheet is not a medical order or emergency response plan. Follow current professional care instructions. For immediate danger or a serious medical emergency, call 911; for crisis support, call or text 988.
Complete privately on paper. Keep securely; do not return to Beyond Barriers. Attach additional pages if needed.
Letter of Intent
Important contacts and support roles
Care and service contacts
- For each: name, role, preferred contact method and backup. Include only details needed by the intended reader.
- Trusted caregivers, healthcare providers, school or work contacts and transportation support
- Case manager, Medicaid/waiver contact, benefits adviser and other service providers
People responsible for specific roles
- Who has agreed to help, what they can do and who is the backup
- Attorney, trustee, representative payee or guardian if appointed; where authority can be confirmed
- Who coordinates the handoff when a caregiver is ill, unavailable or has died
A caregiver, guardian, trustee and Social Security representative payee have different roles. Listing someone here does not give legal authority. Confirm willingness, appointment and the limits of each role separately.
Complete privately on paper. Keep securely; do not return to Beyond Barriers. Attach additional pages if needed.
Letter of Intent
Future arrangements and keeping the plan current
Documents, benefits and future wishes
- Where authorized people can find legal documents, benefit notices and current service plans—without account numbers or access codes
- Renewals, waiting lists, unresolved housing/support needs and questions for the case manager or attorney
- Long-term care wishes, relationships and traditions to preserve; other personal wishes the person wants recorded
Review and secure sharing
- Prepared on / last reviewed / next review date; update after major changes
- Where the current copy is securely kept and who may receive which sections
- Who will update the guide, replace old copies and check that backup supporters remain willing and available
Review at least yearly and after changes in health, supports, housing, benefits or caregivers. Discuss future funding, ABLE accounts and trusts with qualified advisers; do not assume this guide protects benefit eligibility.
Complete privately on paper. Keep securely; do not return to Beyond Barriers. Attach additional pages if needed.