Create Your Supported Decision Making Contract

Supported Decision-Making Questionnaire

Educational supported decision-making questionnaire with optional HIPAA and records releases.

Step 1 of 7 – Basic Information

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Supported Decision-Making Questionnaire

Use this questionnaire to prepare a customized Supported Decision-Making Agreement and, if selected, companion HIPAA and records releases.

Educational and document-preparation use only. State laws and institutional requirements vary.

State of Residence(Required)

County of Residence

Today's Date(Required)

MM slash DD slash YYYY

Your Name(Required)

Your Email(Required)

Your Phone

Decision-Maker Information

Provide information about the adult who will use supported decision-making.

Full Legal Name of the Adult Using Supported Decision-Making(Required)

Preferred Name

Decision-Maker Street Address(Required)

Decision-Maker City(Required)

Decision-Maker State(Required)

Decision-Maker ZIP Code(Required)

Decision-Maker Date of Birth

MM slash DD slash YYYY

Decision-Maker Phone

Decision-Maker Email

How does the decision-maker best understand information?(Required)

How does the decision-maker prefer to communicate choices or decisions?(Required)

Are there any topics where the decision-maker does not want support?

Supporters

List up to four supporters and identify the areas and methods of support for each.

How many supporters do you want to include?(Required)

Supporter 1

Supporter 1 Full Name(Required)

Supporter 1 Street Address

Supporter 1 City

Supporter 1 State

Supporter 1 ZIP Code

Supporter 1 Phone

Supporter 1 Email

Relationship of Supporter 1 to the Decision-Maker(Required)

Supporter 1 May Help In These Areas

Medical care

Mental health care

Benefits

Money and budgeting

Banking

Education or training

Employment

Housing

Services and supports

Legal paperwork

Technology and communication

Personal and social decisions

Other

Supporter 1 May Help In These Ways

Help gather information

Help explain choices

Help compare options

Help communicate decisions

Attend meetings or appointments

Help organize records

Help request information if allowed

Help carry out decisions chosen by the adult

Other

Other Details for Supporter 1

Supporter 2

Supporter 2 Full Name

Supporter 2 Street Address

Supporter 2 City

Supporter 2 State

Supporter 2 ZIP Code

Supporter 2 Phone

Supporter 2 Email

Relationship of Supporter 2 to the Decision-Maker

Supporter 2 May Help In These Areas

Medical care

Mental health care

Benefits

Money and budgeting

Banking

Education or training

Employment

Housing

Services and supports

Legal paperwork

Technology and communication

Personal and social decisions

Other

Supporter 2 May Help In These Ways

Help gather information

Help explain choices

Help compare options

Help communicate decisions

Attend meetings or appointments

Help organize records

Help request information if allowed

Help carry out decisions chosen by the adult

Other

Other Details for Supporter 2

Supporter 3

Supporter 3 Full Name

Supporter 3 Street Address

Supporter 3 City

Supporter 3 State

Supporter 3 ZIP Code

Supporter 3 Phone

Supporter 3 Email

Relationship of Supporter 3 to the Decision-Maker

Supporter 3 May Help In These Areas

Medical care

Mental health care

Benefits

Money and budgeting

Banking

Education or training

Employment

Housing

Services and supports

Legal paperwork

Technology and communication

Personal and social decisions

Other

Supporter 3 May Help In These Ways

Help gather information

Help explain choices

Help compare options

Help communicate decisions

Attend meetings or appointments

Help organize records

Help request information if allowed

Help carry out decisions chosen by the adult

Other

Other Details for Supporter 3

Supporter 4

Supporter 4 Full Name

Supporter 4 Street Address

Supporter 4 City

Supporter 4 State

Supporter 4 ZIP Code

Supporter 4 Phone

Supporter 4 Email

Relationship of Supporter 4 to the Decision-Maker

Supporter 4 May Help In These Areas

Medical care

Mental health care

Benefits

Money and budgeting

Banking

Education or training

Employment

Housing

Services and supports

Legal paperwork

Technology and communication

Personal and social decisions

Other

Supporter 4 May Help In These Ways

Help gather information

Help explain choices

Help compare options

Help communicate decisions

Attend meetings or appointments

Help organize records

Help request information if allowed

Help carry out decisions chosen by the adult

Other

Other Details for Supporter 4

Areas of Support

Select the areas this agreement should cover.

Which areas should this agreement cover?(Required)

Medical treatment and appointments

Choosing providers

Medications

Health insurance

Mental health services

SSI, SSDI, Medicaid, Medicare, or other benefits

Budgeting and money management

Banking

Paying bills

Education and training

Employment

Housing and living arrangements

Service planning

Transportation

Technology and devices

Community and social activities

Legal and administrative paperwork

Other

Additional Areas to Include

How should supporters work together?

Supporters may help separately

Supporters should consult one another when possible

Only the supporter assigned to that area should help

Additional Instructions About How Supporters Should Work Together

Optional HIPAA Authorization

A supported decision-making agreement alone may not be enough for healthcare providers to share protected health information. You can include a short HIPAA Authorization if desired.

Include HIPAA Authorization?(Required)

Yes

HIPAA Authorization Should Cover

General medical records

Appointment information

Medications

Mental health treatment information

Developmental disability records

Insurance information

Lab and test results

Hospital records

Care coordination records

Other

HIPAA Authorization Expires

When I revoke it

One year from signing

Three years from signing

On a specific date

HIPAA Expiration Date

MM slash DD slash YYYY

Optional Records Release

This short records release may help with agencies, schools, service providers, insurers, housing providers, and other record holders, subject to their own forms and policies.

Include General Records Release?(Required)

Yes

Records Categories Covered

Benefits records

Social Security or SSI records

Medicaid or Medicare records

School or training records

Employment records

Housing records

Service provider records

Insurance records

Banking or financial information

Legal or administrative paperwork

Other

Records Release Expires

When I revoke it

One year from signing

Three years from signing

On a specific date

Records Release Expiration Date

MM slash DD slash YYYY

Are any related documents also being used?

HIPAA release

Healthcare directive

Power of attorney

Education release

Representative payee arrangement

Trust planning

ABLE account planning

None at this time

Safeguards and Signing Preferences

Review the basic protections and signing preferences for this document package.

Include these protections in the agreement(Required)

Supporters do not make decisions for the adult

Supporters must respect the adult’s wishes and preferences

Supporters may not use pressure or undue influence

The adult may revoke this agreement at any time

Any supporter may resign at any time

The agreement should be reviewed yearly

The agreement ends at the death of the adult

The agreement should be interpreted under applicable state law

How do you expect the document to be signed?

Signed only

Signed with two witnesses

Signed before a notary

Signed with witnesses and notary

Special signing or use instructions

Before You Submit

Please review your answers carefully. This questionnaire is for educational and document-preparation purposes only. Laws vary by state, and institutions may require their own forms.

Educational Use Acknowledgment(Required)

I understand this questionnaire and document are provided for educational and document-preparation purposes.

I understand laws vary by state.

I understand this document may need to be used together with other forms depending on the situation.

I understand institutions may have their own policies about accepting this document.

Additional Notes to Include in the Directions Page

Supported Decision Making Document

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Supported Decision-Making Questionnaire

Supported Decision-Making Questionnaire

Decision-Maker Information

Supporters

Supporter 1

Supporter 2

Supporter 3

Supporter 4

Areas of Support

Optional HIPAA Authorization

Optional Records Release

Safeguards and Signing Preferences

Before You Submit

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