1. Important Info

2. I live at ___________ My address is: If applicable include picture of apartment or building

3. 9-1-1
Call in case of an EMERGENCY for medical, safety, and fire.
Tell them if you need
Fire EMS Police

4. 24/7 Crisis Hotline: _________________________
If you’re feeling really sad
or really angry and need
someone to talk to you can
call the crisis hotline day or
night. You are NOT alone!

5. Facility Name: Manager Name: Phone:
Contact Manger or anyone in the office with questions about your rent and water bills. You can also call the office with problems that you have with the apartment like a broken sink or if you need a light bulb replaced.

6. My Insurance: ________________
Service Coordinator Name:
Insurance name,
Service Coordinator
Phone:
Insurance name helps with medical supplies, and home health questions. They are who to contact with any medical and insurance questions.

7. Agency: First and last name Social Worker Phone:
Your Social Worker will be with you for a year after you move, to make sure you are doing well in your new home. This includes helping you to follow up with your doctors, medications, nutrition, hygiene, and to make sure you’re having fun.

8. Personal Attendant Name: Personal Attendant Phone:
Your attendant works for company name and will help you with everyday activities like personal hygiene as well as cleaning, laundry, and grocery shopping
If your attendant does not come one day you can call company at pone number

9. Home Health Nurse Name: Phone:
Your nurse can assist you with getting medication refilled, health issues that arise, and obtaining referrals for services like occupational therapy or speech therapy

10. Public Transporation
Call ________days in advance to schedule a ride Reservation Phone Number: Cost of fare: What to bring: Pickup location and time:

11. Medicaid Transport Phone number
You can use Medicaid Transport to go to any medical appointments. You need to call at least 48hrs in advance.
You need to give them
Your Medicaid Number (Your number is)
The address you will be leaving from
The address you will be going
The time you need to be there and the time you need to be picked up

12. 2-1-1
You can call for help finding any services that you need like food pantries, and help set you up with food stamps.

13. Add your own numbers:
Who:____________________ Number: ________________ Agency: _________________ Who: ___________________

14. Add your own numbers:
Who:____________________ Number: ________________ Agency: _________________ Who: ____________________ Number: _________________ Agency: __________________

15. Add your own numbers:
Who:___________________ Number: ________________ Agency: _________________ Who: ___________________