First Application X Follow-Up Application X

Individual help plan from the LVR - Basic form -

Surname , GP-No.

IHP for the period of until

First application Follow-up application Filled in by the applicant/person entitled to benefits with the participation of (people) using the aids/resources (technical support, sign language, tactile signing...) Applicant/person entitled to benefits

Surname First name Date of birth

Occupation Marital status GP number

Number and age of children Number of children in your own household

Postcode Town/city Street

Phone Fax Email The following person is available for queries Surname First name Postcode Town/city Street Telephone Fax Email

Legal assistance or authorized person available yes no Surname First name Postcode Town/city Street Telephone Fax Email Mandatory: provide details on sphere of activity/reservation of consent

Type of disability as defined in the integration assistance regulations (Eingliederungshilfeverordnung) - please enclose current medical reports

Physical disability Mental disability Psychological disability Addiction

Diagnosis/diagnoses according to ICD-10

Clear definition of diagnoses, primary diagnosis

Current care level according to decision of the healthcare insurer Care level ‘0’ I II III None Limited skills for everyday life Please enclose present expert opinion of the MDK and decisions of other (primary) service providers Comments and notes

Current degree of disability according to SGB IX Please enclose assessment decision of the pension office

Surname , GP-No.

I have been informed that I can make use of the benefits in the form of a personal budget.

I am applying for the following benefits, partly for my personal budget:

I am applying for the following benefits, entirely for my personal budget:

I have been instructed that the personal data collected in the LVR’s individual help plan will solely be used to determine an individual’s need for assistance, the benefits required as well as creating the overall plan in accordance with § 58 SGB XII (German social security statute book). I understand that LVR will check whether it has a responsibility for my case and, where necessary, pass my application on (or parts thereof) to other competent benefit providers in accordance with § 14 SGB IX. I hereby agree to my personal data being passed on to competent social security providers.

Location, date

Applicant signature

Signature of legal representative/ authorised person

Comment: An explanation of the personal budget as personal money in simple language can be found in the appendix to this set of forms.

DECLARATION ON THE HANDLING OF PERSONAL DATA as part of the individual help plan of the Landschaftsverband Rheinland

Legal assistance/authorized person available Surname First name

I have submitted an application for integration assistance to a supra-regional provider of social security for which an individual help plan has been developed.

I have been informed that this help plan may be presented at the competent regional help plan conference (HPC).

The central duty of the help plan conference (HPC) is bringing together regional expertise for promoting person-centred, quality-ensured supportive services for people with disabilities in terms of § 53 SGB XII who re- quire benefits in order to participate in life in the community. In its work, the HPC pursues the goal of ensuring disabled people receive the support they need where they live. Members of the HPC agree in writing to maintain confidentiality both towards those entitled to receive benefits, as well as all other people involved, regarding personal data that is received in written or verbal form. The members ensure that the documents entrusted to them are handled with confidence and stored safely.

The HPC comprises specialists who are needed for advice in individual cases.

Members of the HPC are basically:  Supra-regional social security providers  Local social security providers  Health office/coordination for disabled people  Up to 2 representatives from outpatient providers  Up to 2 representatives from inpatient providers  1 representative from SPZ/KoKoBe/addiction counselling

I am in agreement that my help plan can be discussed at the HPC with mention of my name unless re- voked.

I would like my help plan to only be discussed in an anonymised form at the HPC and thereby prevent conclusions being drawn about my person.

I would like to take part in the help plan conference (HPC).

I would not like to take part in the help plan conference (HPC).

Applicant signature Signature of legal representative/ person entitled to benefits/ authorised person

Individual help plan from the LVR - Inter - view guide -

First IHP Continuation of the IHP from No. GP-no.:

For the period from until Created on

Important notice: Please do not enter any personal data on the following pages (name, address...) since, in this version, the help plan is only allowed to be saved electronically in an anonymised form due to data protection requirements. © Landschaftsverband Rheinland 3.1, Version 08/2015 Page 5 of 13 Created by the applicant/person entitled to benefits  With the participation of third parties  While using aids/resources (technical support, sign language, tactile signing)

Gender Year of birth

Occupation Marital status

Number and age of children Number of children in your own household

Legal assistance has been arranged Yes No

Details on sphere of activity/reservation of consent must be provided

Or legal authorisation has been granted Yes No

Type of disability as defined in the integration assistance regulations

Physical disability Mental disability Psychological disability Addiction

Diagnosis/diagnoses according to ICD-10

Clear definition of diagnoses, primary diagnosis:

Current care level according to MDK expert opinion Care level: 0 I II III None

Limited skills for everyday life

Current degree of disability according to SGB IX

Individual help plan from the LVR - Interview guide -

GP-no.

Other or primary benefits (Tick all answers that apply)

Please mark with a cross where applicable Domestic help Care services in accordance with SGB XI Additional services in accordance with § 45 b SGB

XI Home care in accordance with SGB V Other (please name) Services for medical rehabilitation Sociotherapy Physiotherapy/occupational therapy/speech therapy Psychotherapy

Other (please name)

Services to enable participation in working life Workshop for disabled people

Other services to enable participation in working life (please name) Services in accordance with social compensa- tion law (Entschädigungsrecht) (please name)

Youth welfare services in accordance with SGB VIII (please name) Other services (please name)

Please enclose decisions from the 12 months prior to submitting the application

GP-no.

II. How and where I currently live (Description of the current situation: living, working, social relationships, spare time and other things which are important to me)

SupplementaryHow and where expert I want perspective to live (facts, conditions and circumstances that are of importance to the specific case)

What I plan to do during the day (e.g. work)

How I want to live with/interact with other people (Relationships with other people, not co-habitation)

What I intend to do during my spare time

Other things which are very important to me

III. What I can do without any great difficulty (without support from or use of tools/aids)

Supplementary expert perspective

IV. Who or what can help me now to live how I wish (e.g. support from tools/aids, through room conditions or people)

Supplementary expert perspective (facilitating factors e.g. by changing surroundings or gaining support through relationships)

GP-no.

V. What I am not good at or cannot do at all (e.g. What cannot be accomplished without the use of tools/aids or support of people?)

Supplementary expert perspective (impairment to activities, e.g. learning and applying knowledge, communication, mobility, self-sufficiency, social connections)

VI. Who/what is hindering me from living how I wish (e.g. lack of support from aids/tools or people, exist- ing obstacles)

Supplementary expert perspective (lack of facilitating factors/environmental factors)

VII. Further important aspects needed to understand me or my situation ( e.g. previous experi- ences, personal characteristics, lifestyles, short description of personal history, significant impairments and medical/pedagogic- al background)

Supplementary expert perspective (personal factors such as personal characteristics, particular lifestyles or prefer- ences; not characteristics of the impairment to health)

GP-no.

IX. How was this result achieved? What The objective was... helped? What was less helpful or un- VIII. What should be achieved specifically in the helpful? long run? Achieve Partly Not (This does not only include assistance from Please retrieve all objectives from the last IHP and d achieved achieved professionals but also unplanned events add changes after presentation to the HPC and factors.) Please place a cross where applicable

GP-no.

X. What specifically should be XI. What should be done to achieved in the future? (The By when? achieve the goals? (Act- number of s.m.a.r.t. objectives Date Re- Who should Where should No. No. ivties/actions required to are formulated as to be straight- quested do this? it be done? achieve the desired condi- forward for the person entitled to time period tion/status) benefits)

Time of day Form of service (please tick) (please tick) Name and address of the intended service provider No Scope in (In the case of several service providers, please Day- Night Service in Monetary Personal hours/minutes; assign each to the respective providers) . time time kind benefit budget units/week