paragonpdx support services

SSI / SSDI Filing Worksheet

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

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:

Vital Documents Checklist

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

Why this matters: Without ID, a person can't get housing, benefits, a job, or medical care. These documents unlock everything else. Start here.

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?

Housing Action Plan

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

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.

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):

Check-up Visit

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

How to use this: A follow-up visit with someone you've already seen. What's changed since last time? What's stuck? What still needs doing?

How Are They Doing?

How is the client doing since the last visit?

What changed — good or bad?

Where are they sleeping now?

Review Each Area

Documents

On track Stuck — needs help

Document notes:

Benefits (SSI/SSDI, SNAP, OHP)

On track Stuck — needs help

Benefits notes:

Housing

On track Stuck — needs help

Housing notes:

Health

On track Stuck — needs help

Health notes:

Next Steps

New needs since last time?

What will you do before the next visit?

What will the client do before the next visit?

Next check-up date:

Check-up added to HMIS case notes

✓ Signatures

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

Worker signature:

Date:

Consent to Share

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

What this is: The client's written permission for you to share their information with helpers and providers. Without this, doctors, shelters, and benefits offices legally cannot talk to you about them.

I give permission to share my information with:

Doctor / clinic Shelter / housing program SSA / benefits office (SSI, SSDI, SNAP, OHP) Mental health provider Substance use treatment program HMIS (homeless services database)

Other person or agency:

They may share this about me:

Contact information Health information Benefits information Housing information All of the above

How long this lasts

This permission lasts 1 year from the signing date below, unless the client cancels it sooner. The client can cancel at any time by telling you in person or in writing.

Good until (date):

Client understands they can cancel this anytime

✓ Signatures

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

Worker signature:

Date:

Benefits Tracker

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

How to use this: One line per benefit. Update it every time something changes — applied, approved, denied, renewed.

OHP (Oregon Health Plan)

Needs to apply Applied — waiting Approved Denied — appeal?

Case / member number:

Renewal date:

SNAP (food benefits)

Needs to apply Applied — waiting Approved Denied — appeal?

Case number:

Renewal / recertification date:

SSI / SSDI

Needs to apply Applied — waiting Approved Denied — appeal deadline matters!

Appeal deadline (if denied):

Notes:

Other benefits

TANF, GA, unemployment, other — status:

Next action needed (what + by when):

✓ Signatures

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

Worker signature:

Date:

Encounter Log

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

How to use this: A quick note each time you see them — even a 5-minute check-in counts.

This visit

Date and time:

Where did you see them?

In person By phone / text

What did you do together?

How are they doing? (mood, safety, concerns)

What do they need next?

Plan before next contact:

Added to HMIS case notes

✓ Signatures

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

Worker signature:

Date:

Appointment Tracker

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

How to use this: Log each appointment. The ride and reminder are what get people there.

Appointment 1

Date and time:

Where / who with:

What for:

Ride arranged Reminder given Went Missed — needs rescheduling

Result / notes:

Appointment 2

Date and time:

Where / who with:

What for:

Ride arranged Reminder given Went Missed — needs rescheduling

Result / notes:

Appointment 3

Date and time:

Where / who with:

What for:

Ride arranged Reminder given Went Missed — needs rescheduling

Result / notes:

✓ Signatures

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

Worker signature:

Date:

Belongings Record

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

Why this matters: When a camp gets cleaned up, property gets moved or stored. This record helps get it back.

What they have

Bags / packs (how many, what they look like):

Tent / sleeping gear:

Important documents they carry:

Electronics (phone, charger, etc.):

Other valuables / keepsakes:

Where it's kept

Where is it stored right now?

Storage contact name and phone:

What do they keep on them at all times?

If property was moved during a cleanup — where did it go?

✓ Signatures

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

Worker signature:

Date:

Veteran Check

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

Why ask: Veterans can get VA health care, housing help, and benefits that civilians can't. Many don't know they qualify.

Service history

Served in the US military Did not serve

Branch:

Years served:

Discharge type (if known):

VA connection

Has DD-214 (discharge papers) Needs help getting DD-214 Enrolled in VA health care Wants veteran housing / benefits — refer

Notes:

✓ Signatures

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

Worker signature:

Date:

Pet Note

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

Why ask: Many people won't enter shelter without their animal. Knowing the pet situation keeps placements from falling apart.

The animal

Has an animal No animal

Type / breed / name:

Vet needs (shots, food, medical):

Referred to pet-friendly shelter Referred to vet / pet services

Notes:

✓ Signatures

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

Worker signature:

Date:

Universal Needs Assessment

Client Name:

DOB:

HMIS ID:

Date:

Your Name:

How to use this: Check every need this person has, across all categories. Then tap Build referral list at the bottom — the app makes a per-person list showing where to find help for each need in the compassion compass.

🏠 Shelter & Housing

Needs emergency shelter tonight Needs transitional housing or shelter program At risk of losing current housing Needs help with rent / deposit / application fees

Shelter notes:

🍕 Food

Needs a meal today Needs groceries / food box No way to cook or store food Needs help applying for SNAP

Food notes:

🩹 Medical & Health

No health insurance — needs OHP Needs a doctor or clinic Mental health support wanted Needs prescriptions / medication refill Dental problems Wounds or infection — needs care urgently Chronic condition (diabetes, asthma, blood pressure, etc.)

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

Health notes:

🚨 Crisis & Safety

In crisis right now Feels unsafe where they are staying Domestic violence concern Needs a safety plan

Safety notes:

💪 Recovery

Wants detox or treatment — refer now Wants recovery meetings / peer support Needs harm reduction supplies (Narcan, etc.) Substance use + mental health together (needs both)

Recovery notes:

💼 Daily Needs

Needs clothing Needs hygiene supplies Needs a phone / charger Needs laundry Needs transportation / bus fare Needs mail / address service

Daily needs notes:

💰 Money & Benefits

Needs income — job help / day labor Needs help with benefits (SSI/SSDI, SNAP, TANF) Needs help with ID / document fees Needs financial counseling

Money notes:

✨ Other Needs

Legal help needed Veteran — needs veteran services Needs childcare / family support Needs language / interpretation help

Other needs:

✓ Referral List for This Person

Tap the button to build a list from every need checked above. Each need points to where help lives in the compassion compass.

Top concerns for this person:

Referrals made (where, when):

Needs info added to HMIS case notes

✓ Signatures

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

Worker signature:

Date:

paragonpdx support services

PARAGONPDX TERMS OF USE & LIABILITY DISCLAIMER

1. What this app is / Scope of Service

2. Where information lives / Data Storage & Security

3. What can go wrong / Risk of Data Loss

4. Whose job it is / Compliance & Responsibility

5. DISCLAIMER OF WARRANTIES

6. No blame / Limitation of Liability & Indemnification

7. Governing Law and Jurisdiction

8. Electronic Acceptance

Who are you helping today?

Recent

👤 My contact card

🌍 Universal Needs Assessment

🪪 Vital Documents Checklist

📋 SSI / SSDI Filing Worksheet

🏠 Housing Action Plan

🔄 Check-up Visit

🤝 Consent to Share

💳 Benefits Tracker

📝 Encounter Log

📅 Appointment Tracker

🎒 Belongings Record

🎖 Veteran Check

🐶 Pet Note

🔖 Tracking Log

🧭 compassion compass

Tracking Log

✓ This form is complete!

🔖 Tracking & Follow-up

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

Check-up Visit

How Are They Doing?

Review Each Area

Documents

Benefits (SSI/SSDI, SNAP, OHP)

Housing

Health

Next Steps

✓ Signatures

Consent to Share

I give permission to share my information with:

They may share this about me:

How long this lasts

✓ Signatures

Benefits Tracker

OHP (Oregon Health Plan)