Paragon PDX Support Services

① Client Info & Living Situation

Full legal name? Other names used?

Social Security number?

Born in the US? (If no — immigration status?)

Where did you sleep last night?

How long homeless?

Shelters? Which ones, when?

Outreach teams or case managers?

Best way to reach you?

② Which Benefit?

SSI only — little/no income, no work history needed SSDI only — has work history, paid into Social Security Both — file for both, let SSA decide

Not sure? File for BOTH. Costs nothing extra.

Filing for (SSI / SSDI / Both):

③ SSA Forms (from ssa.gov)

SSA-8000-BK — SSI application (SSI/Both) SSA-16-BK — SSDI application (SSDI/Both) SSA-3368-BK — Disability Report SSA-3369-BK — Work History (SSDI/Both) SSA-3373-BK — Function Report SSA-827 — Medical Release (one per provider) SSA-1696 — Representative (signed by both)

④ Identity Documents

Photo ID Social Security card or verified SSN Birth certificate or proof of citizenship Immigration docs (if not a citizen)

Missing? Plan to get it:

⑤ Medical

What health problems keep you from working?

When did each start?

Doctors? (Names, clinics, addresses, phones)

ER/hospital visits? Where, when?

Medications? (Name, dose, prescriber)

Surgeries, X-rays, MRIs, tests?

Mental health treatment? Who, where?

Drug/alcohol treatment? Where, when?

Records gathered:

Primary care Specialists Hospital / ER Mental health Substance use Medication list Test results

⑥ HMIS Records (you pull)

Client profile printout Homeless verification Chronic homeless docs (if 12+ mo) Service history Case notes Assessment scores

⑦a Financial (SSI/Both)

Income now? From where, how much?

Benefits already? (SNAP, TANF, GA, veterans?)

Income proof or zero-income statement Bank statements or no-account statement Vehicle/property info

⑦b Work History (SSDI/Both)

Last job? (Employer, duties, dates)

Other jobs in last 15 years?

Physical duties of each?

Why leave each?

When did you stop being able to work? What happened?

W-2s Tax returns SSA earnings record Past employer contacts

⑧ Daily Life (Function Report)

Normal day, morning to night?

Dress, bathe, cook, clean without help?

How far can you walk? Lift/carry?

How long sit? Stand?

Trouble concentrating/remembering?

Trouble getting along with people?

⑨ Review & Signatures

Anything about your health I missed?

Anyone else I should talk to?

Client understands what was filed Client agreed I can be contacted by SSA All forms signed/dated SSA-1696 signed by both Copies given to client

Client signature — tap the box and sign with your finger:

Sign inside the box above.

Preparer signature:

Date:

✓ Filed

Date submitted:

Confirmation #:

Follow-up notes:

① State ID / Driver's License

Do they have it?

Yes — valid ID Expired Lost/Stolen — needs replacement Never had

ID number (if known):

What state was it from?

Checked current DMV fee Gathered proof of identity Gathered proof of address (shelter letter, HMIS printout) Went to DMV with client ID received

Notes / appointment / receipt #:

② Social Security Card (FREE replacement)

Yes — has the card Knows the number — no card Lost — needs replacement Never had / doesn't know Applied online at ssa.gov OR visited SSA office with client Card received (~2 weeks by mail)

Notes / confirmation #:

③ Birth Certificate

Yes — has certified copy No — needs to order

Birth state / county:

Mother's maiden name:

Found correct Vital Records office Checked fee Order submitted Certificate received

Notes / order #:

④ Immigration Docs (if not a US citizen)

US citizen — skip Has green card / PR card Has other immigration docs Referred to immigration legal aid

Document type / number:

⑤ Health Insurance (OHP / Medicaid)

Yes — enrolled in OHP No — needs to apply Not sure — check status Applied (OregonHealthCare.gov or phone) Helped pick a CCO Enrollment confirmed

CCO name / member ID:

⑥ SNAP / EBT Card

Yes — receiving SNAP No — needs to apply Lost card — needs replacement Applied through Oregon DHS Reported homeless status EBT card received

Notes / case #:

✓ Signatures

Client signature — tap the box and sign with your finger:

Worker signature:

Date:

✓ Summary

State ID — done SS card — done Birth certificate — done Immigration — done / N/A OHP — done SNAP — done

Still missing? Next steps:

Copies stored where?

① Immediate Safety & Basic Needs FIRST

Can't work on anything else if they're not safe, fed, and have somewhere to be. Handle today.

Shelter tonight?

Emergency shelter bed tonight On shelter waitlist Has tent / safe outdoor spot Staying with someone temporarily

Shelter name / waitlist / location:

Connected to meal site / food pantry Has water access Asked about safety concerns Safety plan in place if needed

Safety notes:

Shower access arranged Clean clothes / hygiene supplies Phone / charging access

② Vital Documents FOUNDATION

No ID = no housing, no benefits, no job. Unlocks everything below.

State ID — has it or in progress SS card — has it or in progress Birth certificate — has it or in progress

What's missing? Status:

Use the Vital Documents form for the full step-by-step.

③ Income & Benefits

Money coming in is what makes housing sustainable.

SNAP — applied or receiving OHP — enrolled SSI/SSDI — assessed SSI/SSDI — application in progress TANF / GA / Veterans — checked

Benefit status / case #s:

Currently employed Wants to work — referred to employment program Not able to work (health/disability)

Work notes:

④ Health

Untreated health problems keep people from staying housed. Connect to care early.

Has primary care doctor/clinic Urgent health issues addressed Has needed medications Screened for mental health needs Connected to mental health provider Asked about substance use (no judgment) Wants treatment — referred

Health notes / referrals:

Use the Health Needs Assessment form for the full screening.

⑤ Housing — The Goal GOAL

Housing first: get them housed, then keep working on the rest.

Housing assessment completed (VI-SPDAT or local tool) In coordinated access / housing queue

Score / queue position:

Emergency shelter (short-term) Transitional housing — applied Rapid rehousing — referred/enrolled Permanent supportive housing — waitlisted Housing voucher — applied Private rental — helping with search/deposit

Housing status / next step:

Barriers:

Criminal background — plan in place Eviction history — plan in place Bad credit / debt — plan in place No rental history — plan in place

Barrier notes:

⑥ Support Network

People stay housed when they're connected.

Ongoing case manager assigned Connected to peer support / community Family/friends as support identified Housing stability plan created Follow-up scheduled

Case manager / contact:

Next follow-up date:

✓ Signatures

Client signature — tap the box and sign with your finger:

Worker signature:

Date:

✓ Action Summary

Top 3 priorities right now:

Accomplished today?

Very next step — who's doing it?

HMIS notes entered? (date):

① Mental Health Screening

Nearly half of Portland shelter residents have a severe mental illness. Ask directly, no judgment.

Have you ever been diagnosed with a mental health condition? Which one(s)?

Schizophrenia Bipolar disorder Depression Anxiety PTSD Other / not diagnosed but struggling

Are you taking any medication for mental health? What?

When did you last see a mental health provider? Who/where?

Wants mental health help — referred Crisis risk — safety plan done, crisis line given

If they mention harming themselves or others: stay with them, call the Multnomah County Crisis Line or 988. Don't leave them alone.

② Substance Use Screening

Fentanyl is the leading cause of overdose death. Most providers can't treat addiction and mental health together — note both.

Do you use alcohol, fentanyl, meth, heroin, or anything else? What and how often?

Alcohol Fentanyl Meth / stimulants Heroin / opioids Other

Have you ever overdosed? When? Was naloxone (Narcan) used?

Uses alone (higher overdose risk — discussed) Narcan given / knows where to get it Wants treatment — referred to detox / program Harm reduction info given

Treatment history — where, when, what happened?

③ Physical Health Screening

Wound infections, untreated chronic conditions, and lack of primary care are everywhere on the street.

Wounds & infections — check visually if they'll let you

Visible wounds, sores, or abscesses Signs of infection (redness, swelling, warmth, pus) Referred for wound care urgently

Wound notes / location on body:

Chronic conditions

Do you have asthma, diabetes, high blood pressure, HIV, Hep C, or anything ongoing?

Asthma Diabetes High blood pressure HIV / Hep C Chronic pain Other chronic condition

General

When did you last see a doctor? Where?

Any recent ER or hospital visits? For what?

Dental problems? (Tooth pain is a top street complaint)

Vision / hearing problems?

④ Healthcare Access

Portland has the worst primary care access of any major city studied — 61-day median wait. Know the barriers.

Has OHP / health insurance Has a regular doctor or clinic

Clinic / doctor name:

What's stopped you from getting care? (No ID, no insurance, wait times, transportation, fear, language?)

Referred to low-barrier clinic Transportation to appointment arranged

⑤ Medications

What medications do you take? (Name, dose, who prescribed)

Has meds with them right now Out of meds — needs refill Meds were lost or stolen Help getting refill arranged Needs safe storage for meds

Medication notes:

✓ Signatures

Client signature — tap the box and sign with your finger:

Worker signature:

Date:

✓ Health Summary & Referrals

Top health concerns for this person:

Referrals made (where, when):

Urgent follow-up needed? What and by when?

Health info added to HMIS case notes Info shared with SSI/SSDI medical section (if filing)

Paragon PDX Support Services

📋 SSI / SSDI Filing Worksheet

🪪 Vital Documents Checklist

🏠 Housing Action Plan

🩺 Health Needs Assessment

✓ This form is complete!

SSI / SSDI Filing Worksheet

① Client Info & Living Situation

② Which Benefit?

③ SSA Forms (from ssa.gov)

④ Identity Documents

⑤ Medical

Records gathered:

⑥ HMIS Records (you pull)

⑦a Financial (SSI/Both)

⑦b Work History (SSDI/Both)

⑧ Daily Life (Function Report)

⑨ Review & Signatures

✓ Filed

Vital Documents Checklist

① State ID / Driver's License

Do they have it?

② Social Security Card (FREE replacement)

③ Birth Certificate

④ Immigration Docs (if not a US citizen)

⑤ Health Insurance (OHP / Medicaid)

⑥ SNAP / EBT Card

✓ Signatures

✓ Summary

Housing Action Plan

① Immediate Safety & Basic Needs FIRST

Shelter tonight?

② Vital Documents FOUNDATION

③ Income & Benefits

④ Health

⑤ Housing — The Goal GOAL

Barriers:

⑥ Support Network

✓ Signatures

✓ Action Summary

Health Needs Assessment

① Mental Health Screening

② Substance Use Screening

③ Physical Health Screening

Wounds & infections — check visually if they'll let you

Chronic conditions

General

④ Healthcare Access

⑤ Medications

✓ Signatures

✓ Health Summary & Referrals