7 . Statement of Desires Concerning Living Arrangements
If you wish to indicate your desires , you may INITIAL the statement or statements that reflect your desires and / or write your own statements in the space below .
If the statement reflects your desires , initial the box next to the statement .
1 . I desire to live in my home as long as it is safe and my medical needs can be met . My agent may arrange for a natural person , employee of an agency or provider of community-based services to come into my home to provide care for me . When it is no longer safe for me to live in my home , I authorize my agent to place me in a facility or home that can provide any medical assistance and support in my activities of daily living that I require . Before being placed in such a facility or home , I wish for my agent to discuss and share information concerning the placement with me .
2 . I desire to live in my home for as long as possible without regard for my medical needs , personal safety or ability to engage in activities of daily living . My agent may arrange for a natural person , an employee of an agency or a provider of community-based services to come into my home and provide care for me . I understand that , before I may be placed in a facility or home other than the home in which I currently reside , a guardian must be appointed for me .
If you wish to change your answer , you may do so by drawing an “ X ” through the answer you do not want and circling the answer you prefer .
Other or additional statements of desires : _____________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________
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