Medical Intake form

Worksheet: Engaging in Treatment
Today's Date

MonthDayYear
Date
This worksheet is designed to help you reflect on your loved one’s current level of engagement with treatment, including medication management and healthcare management to better determine whether a more structured housing environment or a more independent living situation might be the best fit. Supportive housing can be simplified into three categories: high, moderate, or low support.
- High support: structured or supervised housing with round-the-clock care, treatment integration, and preplanned schedules.
- Moderate support: a blend of structured support with some limited independence depending on the ongoing needs and situation.
- Low support: minimal support while gradually working towards more independence in recovery.
When you've completed the worksheet, you can print the page to store in your records or save the form to your personal Jotform account. S&PAA does not keep documentation from completed worksheets.
Medication Management

Select the most relevant and concerning items for the status of your loved one’s current skills in medication management:
Highest Support

They require hands-on assistance to take their medication at the correct time(s) every day.They need regular assistance to address basic challenges with their medications (e.g., side effects, effectiveness) with you or a healthcare provider.They need regular help identifying when prescriptions need refilling.
Moderate Support

They take their medication at the correct time(s) every day (with frequent reminders).They are able to communicate any challenges with medications (e.g., side effects, symptom changes) to you or a healthcare provider.They need help navigating the process of picking up prescriptions at the pharmacy. They need someone to help ensure proper steps are followed for blood work (for certain medications) or other routine lab monitoring.
Lowest Support

They manage their medication schedule with only some reminders (e.g., setting alarms, using a pillbox, or having pharmacy pack pills by date/time).They can self-assess and describe the impact of their medications, such as side effects or changes in symptoms.They can pick up prescriptions at the pharmacy or get delivery on their own.
Healthcare Management

Select the most relevant and concerning items for the status of your loved one’s current skills in healthcare management:
Higher Support Needs

They know the roles of their healthcare providers, such as their psychiatrist, therapist, etc.They need someone who can manage all appointments with their healthcare providers.
Moderate Support Needs

They know the names of their healthcare providers.They can occasionally schedule, keep, cancel, or reschedule appointments, but they need consistent help and are starting to get involved.
Low Support Needs

They know how to contact their healthcare providers.They can schedule, keep, cancel, or reschedule their own appointments but need occasional reminders and take the steps themselves sometimes.
Treatment Plan Management

Select Yes (Y) or No (N) for each of these questions if they are concerning:

General Treatment Plan

	Yes	No
Is there an established treatment plan (e.g., prescribed medications, therapy sessions, follow-up appointments)?
Are they aware of the importance of following this plan consistently?

Ability to understand and communicate the plan

	Yes	No
Do they understand why medication and therapy are important for managing schizophrenia or psychosis?
Can they recognize early signs of relapse (such as changes in sleep, mood, or increased hallucinations/delusions)?
Do they know whom to contact if they experience worsening symptoms (e.g., loved ones, crisis hotline, mental health professional)?
Can they communicate clearly about how they feel and what kind of help they might need?

Summary of Most Concerning Items Selected:

Medication Management:

{highestSupport}

{moderateSupport}

{lowestSupport}

Healthcare Management:

{higherSupport}

{moderateSupport135}

{lowSupport}

Treatment Plan Management: (see most recent question)
Next Steps
For any of the most concerning items listed, please transfer those main concerns in the "Build Your Housing Plan” worksheet.
Should be Empty:

Worksheet: Engaging in Treatment

Medication Management

Healthcare Management

Treatment Plan Management