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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:



(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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