2012 Congressional Lame Duck Session - Medicaid, SSI, Social Security Stories

As Congress reconvenes for a post-election session where potential changes or cuts to programs like Medicaid, Supplemental Security Income (SSI), and Social Security may be put on the table, we need your help to put a face on the importance of these programs by sharing lifeline stories about individuals with I/DD. We welcome stories from self-advocates, parents and other family members, chapters of The Arc, other service providers, and friends.

About the Individual

* First Name

* Last Name

Age

* Your relationship to this person

* City

* State

* Zip Code

Email Address:

* Please briefly describe (2-3 sentences) this person’s disability and health conditions (i.e. autism, Down syndrome, seizures, asthma, diabetes, visual, hearing, or communication impairments, etc.)

* Please feel free to add additional information below:

* This person needs help with the following activities (check all that apply)

Do you have a picture of the person you can attach?

Does this person receive SSI or Social Security Disability benefits?

SSI

Social Security Disability benefits

Does anyone else living in the home receive SSI?

Yes

No

* Does this person live....

In his/her own home/apartment [if yes, does the person have roommates?]

With family members

In a group home

Other:

Does this person have a roommate?

Yes

No

About the Services and Supports

Does this person currently receive health care or long term services and supports from Medicaid?

Yes

No

Please check any of the services that he/she receives:

In-home supports	Wheelchair or other durable medical equipment
Communication device or assistive technology	Transportation assistance
Supported employment/Job coaching	Respite care
Occupational, speech, or physical therapies	Day activities/day habilitation
Other:

Does this person receive personal assistance services? Please describe types of services, such as 24/7 supports, AM/PM services, at-work personal assistance, case management, etc.:

How are services under Medicaid vital to this person?

What would happen if these services were lost? (for example, family member forced to quit job, take a second job, leave loved one unsupervised or in unsafe care, place loved one in institution)

Is this person on a waiting list for Medicaid services and supports?

If Yes - What is lacking in the person’s life while they are on a waiting list for services?

About the Income Support

This person’s monthly SSI or Social Security check is spent on (check all that apply)

How is the monthly SSI or Social Security check vital to this person?

What would happen if the monthly check was cut? (for example, unable to pay rent, buy food)

Contact Information

Please provide contact information for the individual completing the survey.

* First Name

* Last Name

Chapter

* City

* State

* Phone Number

* Email Address

* We will use the individual’s first name and photo only with your permission, and will follow up with you if we choose to do so. I authorize release of story/name/image to:

* Indicates Response Required

Dressing	Eating
Bathing	Walking
Shopping	Managing money
Cooking	Communicating
Taking medications	Getting around in the community
Other