Medical Intake form

Worksheet: Financial Analysis
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This worksheet is designed to help you track and organize financial information applicable to determining what housing is appropriate for your loved one living with schizophrenia or a related psychotic disorder. Refer to the “Part 3: Understanding Financial Considerations” of the toolkit to learn more about the various financial factors to keep in mind and note that not all financial options may apply to your loved one’s situation.

Important Note: Eligibility for programs and coverage varies significantly by location and individual circumstances. This worksheet is a tool to help you gather information; always verify details with official sources.

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.
Section 1: Understanding Your Loved One’s Current Financial Situation
Knowing their current income and assets is the first step; and other financial options to build into your analysis of sources of funding to pay for housing. This includes disability, employment, other family assets, and even other external sources.

There are a number of possible income sources, including SSI (Supplemental Security Income), SSDI (Social Security Disability Insurance), other disability benefits, and employment Income. To learn more about SSI and SSDI, see the section below. In addition, your calculations may include support from family members. Be sure to assess what money might be available on hand for initial deposits or ongoing support.
1.1 Supplemental Security Income (SSI) & Social Security Disability Insurance (SSDI)
Supplemental Security Income (SSI) & Social Security Disability Insurance (SSDI) are federal programs that provide income which can be used for housing costs.
Social Security Administration (SSA)

Phone number: 1-800-772-1213
Website: ssa.gov

Ensure your benefits are current and correct, as they may change from year to year. Read the newest updates on the SSA webpage for press releases.

SSA has guidance on your benefit amount based on where you live, and the amount can vary. Visit the SSA webpage on housing to learn more.
Date contacted SSA/reviewed benefits:

MonthDayYear
Date
Representative Payee
If needed, discuss representative payee options with the Social Security Administration. The representative payee is someone the SSA appoints, such as a family member, friend, or agency, to receive and manage SSI/SSDI payments for someone who can't handle their own finances. Their key duty is to spend the person’s benefits on essentials (food, housing, healthcare, etc.) and future planning while acting in the person's best interest.

If you are the individual’s representative payee, then you can handle the finances related to SSI/SSDI payments. If not, go to the representative payee to handle these concerns.
1.2 Temporary Financial Support / Other Programs
Please review financial support pages of the "Part 3: Understanding Financial Considerations" of the toolkit to determine if any of the below might apply to your loved one. Identify any applicable sources in the below section. Pull that funding source into the funding chart in section 1.3.

State/Local Housing Subsidies & Assistance:
State Agency:
Local Program Name:
Duration of Subsidy/Assistance:
Type of Subsidy/Assistance (e.g. rent assistance, emergency assistance, service access, shelter related):
Application Status:
Notes:
Nonprofit Organizations:
Organization Name:
Contact Person/Number:
Duration of Assistance:
Type of Assistance:
Eligibility Requirements:
Notes:
Charitable Organizations:
Organization Name:
Contact Person/Number:
Duration of Assistance:
Type of Assistance:
Eligibility Requirements:
Notes:
Other Temporary Support:
Source:
Type of Assistance:
Duration of Assistance:
Notes:
1.3 Pulling it all together: What are your total possible income sources?

Based on the above analysis, what income / disability / or other sources of income will you have:

	Amount Monthly	Duration of funding	Amount (One Time)
Employment Income
Family Contributions
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Other Disability Benefits
State/Local Housing Subsidies & Assistance
Non-Profit Organizations
Charitable Organizations
Other - Amount available on hand for initial costs/deposit
Other - Amount available for ongoing costs

Calculate your total monthly and write here:
Section 2: Exploring Insurance Options for Housing & Support
Depending on the insurance your loved one currently has, there might be an opportunity to obtain support from them for housing. Insurance is either privately held or through the government (Medicaid or Medicare). Use the following to identify which applies and what services you can glean.
2.2 Private Health Insurance

Be sure to contact the insurance company to confirm coverage for any relevant services or residential care options. Get this in writing if possible, including the sections below to start.
Insurance Company
Policy Number:
Policy Holder Name:
Website for Policy Information:
Contact Phone Number for Benefits/Coverage Questions:
Notes:
Does this policy cover any residential care or support services?

YesNoUnsure
If yes, what specific services or types of housing are covered?
Are there limitations (e.g., duration, specific diagnoses, in-network providers)?
Date contacted insurance company:

MonthDayYear
Date
Summary of information gathered:
2.3 Medicare

Contact Phone Number (1-800-MEDICARE): 1-800-633-4227

Website: medicare.gov

Medicare generally does NOT cover long-term residential care or non-medical support services in a housing setting. However, it may cover specific medical services received while in housing (e.g., doctor visits, therapy).
Medicare Number:
Does the individual have Medicare Part A, B, C, and/or D?
Are there specific medical needs that Medicare might cover while in housing?
Date contacted Medicare/reviewed benefits:

MonthDayYear
Date
Summary of information gathered:
2.4 Medicaid (State-Specific)

Medicaid is often a crucial source for long-term care and support services, but eligibility and covered services vary greatly by state. Contact the state Medicaid office or a local benefits counselor for personalized assistance.

Document below the important details for your state-based Medicaid program and consider what might be available for housing:
State Medicaid Program Name
Medicaid ID Number:
Contact Phone Number for State Medicaid Office:
Website for State Medicaid Information:
Is the individual currently eligible for Medicaid?

YesNoAppliedNeed to Apply
Does the state Medicaid program have waivers or programs that cover:
Residential care (e.g., assisted living, group homes)?

YesNoUnsure
Home and Community-Based Services (HCBS) that can support someone in their housing?

YesNoUnsure
Behavioral health support services in the community?

YesNoUnsure
What are the income and asset limits for these programs?
What specific services are covered (e.g., personal care, case management, behavioral therapy, medication management)?
Date contacted Medicaid office/reviewed state website:

MonthDayYear
Date
Summary of information gathered:
Section 3: Action Plan & Next Steps
Based on the information gathered, use this checklist to plan your next steps.

Review the individual's total monthly income (Section 1).Identify potential insurance sources that seem most promising based on initial research (Section 2).
For the housing you’re considering:

Confirm the exact monthly costs and what is included.Ask specifically which funding sources they accept (e.g., "Do you accept the [State Name] HCBS waiver?").Ask about their application process and any waiting lists.
Section 4: Important Contacts & Notes

Consult a Professional: Consider consulting with a social worker, case manager, or benefits counselor who specializes in disability and housing resources. They can provide invaluable guidance.

Use this space to keep track of important people and information:

	Name	Phone	Email
Case Manager/Social Worker
Benefits Counselor
Key Contact at Potential Housing Option

Notes/reminders:
This worksheet is a starting point, and gathering all this information may take some time and persistence. Don’t forget to be patient and kind with yourself through the process. Remember, you are doing important work in supporting your loved one.
Should be Empty:

Worksheet: Financial Analysis

Section 1: Understanding Your Loved One’s Current Financial Situation

Section 2: Exploring Insurance Options for Housing & Support

Section 3: Action Plan & Next Steps

Section 4: Important Contacts & Notes