Consultation Services Agreement Addendum
Cognitive Interpretation Services
I authorize Roger N. Meyer, DBA "…of a different mind" to act as my cognitive interpreter in any direct face-to-face or teleconferencing meetings between myself with any person or persons, agencies, administrative law judges, independent hearing officers, mediators, or facilitators in matters affecting my personal welfare or that of my family. I authorize Mr. Meyer to be physically present at all such meetings. When necessary, I further authorize Mr. Meyer to audio or video record such meetings.
A list of those persons and/or agencies is listed on the second page of this form.
I enter into this agreement because I am a person with a substantial cognitive impairment that limits my ability to understand certain communication, comply with medical directives, respond according to the reasonable requests of others, or respond in a manner ordinarily expected of a non-impaired persons. I have disclosed my impairment(s) to others, been treated by others as a person with cognitive deficits, and/or diagnosed with a cognitive disability by a medical or professional competent and licensed to provide a diagnosis of cognitive impairment. With this document, I formally invoke the protections of the Americans with Disabilities Act (1990) and Section 504, (Title II) of the Vocational Rehabilitation Act of 1973 as amended protecting persons-with-disabilities. I furthermore invoke other laws, administrative rules, and program operating procedures and directives relating to considerate and respectful treatment of persons with disabilities. My diagnosed or suspected impairment(s) is/are:
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(type of disability)
My impairment limits me in the following manner:
(Initials Required)
____Writing ____Reading ____Reading comprehension
____Verbal response ____Using appropriate words, terms, behaviors
____Planning and other basic personal organizing functions ____Memory
____Understanding others' emotions, purpose, meanings or intent
____Understanding non-verbal communication of others
____Understanding the effect of my behavior or non-verbal responses upon others
____Diminished capacity to provide informed consent without interpretive services
____Requiring certain environmental conditions to be modified, as identified below
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