Medical Intake form

Worksheet: Build Your Final Housing Plan
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Date
This worksheet brings together all of the toolkit content and previous worksheets to help you build a personal plan to find housing as well as to work through the steps needed to get to where you want to be.

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.
Priorities from Prior Worksheets

In assessing your loved one, which areas were of most concern in finding housing?

	Most Concerning	Notes
Overall stability
Managing activities of daily living
Symptom management
Treatment management

The diagram below will help you orient your loved one’s concerns and the types of housing to consider across the recovery spectrum. Think about the most important concerns for your loved one and the level of support needed to meet those concerns where they are:
Housing in your state: And by using the locators for housing found in the “Assessing Housing in Your State,” worksheet see if any of these housing types are available near you.

Below, document potential housing facilities or options that might be the best fit (Yes / Maybe / No):

	Best Option?	Near Me?
Long-Term Care Facility
Supervised Group Home
Supported Housing
Transitional Housing
Apartment
Section 8 / Housing Choice Voucher
Immediate / Short-Term Housing

Putting your plan into action
First, you’ll need to determine which housing options are ones you want to check into. By looking at Part 2: Assessing Housing in Your State, you can come up with a list for housing options. From this list, write down the two where you want to start below.

Reaching out to nearby housing: Use this table to list the potential housing options that seem like a good fit. Then, take the next step by calling to ask questions and, if possible, scheduling an appointment to visit in person to get a clearer sense of each option and move closer to securing a potential housing fit.

	Housing Option #1	Housing Option #2
Facility Name:
Housing Type:
Address:
Have I called?
Have I made an appointment?
Appointment Date:
Time:
Notes:

Housing Facility Assessment
You’ve called the facilities to setup a visit, and it is time to see it in person. The following section can be used during a site visit. Not all sections may be relevant, so please consider the sections most applicable to your loved one’s ongoing situation and needs.
Facility Name
Date & Time of Assessment/Visit:

MonthDayYear
Date
Hour MinutesAM/PM Option
Use the following section (section A – J) to quickly identify what you like and don’t like about a facility.
Section A: Atmosphere & First Impressions (Observe)
Overall Feeling:

Warm?Cold?Clinical?Homey?Chaotic?Calm?
Cleanliness:

Excellent?Good?Fair?Poor?
Staff Demeanor:

Welcoming?Stressed?Engaged?Dismissive?
Resident Appearance/Interaction:

Engaged?Isolated?Well-kept?Distressed?
Noise Level:

Quiet?Moderate?Loud?
Notes:
Section B: Staffing (Ask & Observe)
Staff Availability:

24/7 on-site?Awake overnight?Regular schedule?
Staff Interaction Style with Residents:

Respectful?Patient?Abrupt?Kind?

Staff-to-Resident Ratio (Typical):

	Day	Evening	Night	Weekend
Ratio

Staff Qualifications/Training: (Specifically regarding schizophrenia/psychosis? Crisis intervention? De-escalation?):
Section C: Services & Support (Ask, Observe, Verify)
Medication Management:

Reminders?Supervised?Administered?Secure storage?
Who handles prescriptions?
Mental Health Services:

On-site?Off-site?Therapy?Psychiatry?Coordination with external providers?
Notes:
Holistic Treatment:

Recreational or art therapy?Sensory friendly?
ADL Support Offered:

Hygiene?Grooming?Meals?Laundry?Cleaning?Finances?
Crisis Intervention Plan:
Activities/Programming: Opportunities for...

Hobbies?Exercise?Community outings?Vocational links?Educational links?
Notes:
Meals: (Provided? Mealtimes? Options? Variety? Nutritional value? Special diets accommodated? Dining area observations? Food quality?)
Transportation: (Provided for appointments/outings? Availability? Cost?)
Notes on services and support:
Section D: Physical Environment & Safety (Observe & Ask)
Building Security:

Locked doors?Sign-in/out?Cameras?
Resident Rooms:

Private?Shared?Furnished?Personalization allowed?Locks on doors?Bathroom access?Laundry access?
Common Areas:

Clean?Comfortable?Accessible?Enough space?
Outdoor Space:

Accessible?Safe?Used by residents?Smoking area?
Overall Maintenance & Repair:

Good?Fair?Poor?
Accessibility Features:

Ramps?Grab bars?
Notes on environment & safety:
Section E: Rules, Culture & Community (Ask & Observe)
Key House Rules: (Visitors? Curfew? Chores? Smoking? Phone/Internet access?)
Resident Autonomy/Choice: (Level of independence encouraged? Choice in daily schedule/activities?)
Conflict Resolution: (Handling of disagreements between residents or resident/staff?)
Community Feel: (Sense of camaraderie? Isolation? Staff fosters community?)
Section F: Caregiver Communication & Involvement (Ask)
Communication Policy: (Primary contact? How often are families updated? Emergency contact procedure?)
Visiting Policy: (Hours? Restrictions? Private space available?)
Involvement in Care Planning: (Are families invited to meetings? Is input sought/valued?)
Section G: Cost & Logistics (Verify & Ask)

Use these notes to align the costs of this housing option with the summary of your financials worksheet in order to compare affordability.
Monthly Cost
What's Included:
Extra Costs:

Meds?Supplies?Activities?Transportation?
Other Extra:
Funding Accepted:

Private pay?SSI/SSDI?Medicaid waiver?Insurance?
Application Process (Steps? Waitlist? Required documents? Other notes?):
Section H: Questions to Ask Residents (If appropriate and possible)

(Approach respectfully, briefly introduce yourself, ask if they mind answering a quick question.)
"Are you generally happy living here?"
"Do you feel safe?"
"Does the staff listen to you / treat you well?"
"Is there anything you wish were different?"
Resident Responses/Impressions:
Section I: Red Flags / Concerns
List any specific observations, answers, or feelings that cause concern:
1.
2.
3.
Section J: Overall Summary & Next Steps
Key Strengths / Pros of this Facility:
1. 2. 3.
Key Weaknesses / Cons of this Facility:
1. 2. 3.
Overall Gut Feeling - Rate the level of fit:

Very poorPoorOkStrongVery strong
Specific Next Steps for THIS Facility:
(e.g., Follow up on any open questions, submit application by a certain date, discuss concerns with the property manager or case manager)
Housing Transition Action Plan
Once you've evaluated facilities and have a preferred choice, this worksheet helps you organize the steps needed to apply, get accepted, and plan the move. Breaking this process down can make it feel more manageable and help you as a caregiver to keep the various details organized in one place.
1. Target Housing
Chosen Facility:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Key Contact Person at Chosen Facility:

First NameLast Name
Phone Number
Please enter a valid phone number.
2. Application & Approval Process
Eligibility confirmed:

YesNo (Stop to check)
Required documents gathered:

YesNo (Stop to check)Still Needed
Application Completed

YesIn ProgressNot Started
Application Submitted

YesNot Yet
Received Notification:

AcceptedWaitlist
3. Pre-Move Planning (Start once acceptance is likely/confirmed)
Review Contract/Residency Agreement:

ReceivedReviewedQuestions Asked
Finalize Funding/Payment:

CompletedIn Progress
Coordinate w/ Treatment Team:

ContactedMeeting ScheduledInfo TransferredMove-In Date Confirmed
Set Target Move-in Date:

MonthDayYear
Date
Plan for Belongings

PackedMoving Help NeededStorage Needed
Transportation Plan for Move-In:
Notify Key People/Agencies of Address Change: (e.g., Social Security, Bank, Doctors, Post Office)

List MadeNotifications Sent
4. Post-Move-In Steps
How Often to Check-In with Staff:
Communication Plan with Staff:
Scheduled Initial Care Plan Meeting:

MonthDayYear
Date
Plan for Initial Visits/Support:
1. 2. 3.
Transfer/Update Prescriptions:

DoneTo Do
5. Potential Hurdles & Back-up Plans
If Waitlisted, Plan B:
If Funding Falls Through, Plan B:
If Loved One Changes Mind/Resists, Plan B:
Other Potential Challenge:
6. Caregiver Notes & Reminders
Use this space for your thoughts, feelings, things to remember, self-care prompts:
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: Build Your Final Housing Plan

Priorities from Prior Worksheets

Putting your plan into action

Housing Facility Assessment

Housing Transition Action Plan