Yes No Do you need assistance with your children’s HIV medical care/medications? What is your relationship with children? Do you have other dependents? # of dependents Ages # living with you Yes No If dependents do not live with you, where do they live? Do you need assistance in caring for adult dependents? Yes No What is your relationship with dependents? Comments: Finances and Benefits Since last (re)assessment, there has been: New Need Continuing Need This is a: No changes Changes Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. INCOME AND EXPENSES Yes No Do you have income? If yes, complete chart below: MONTHLY INCOME AMOUNT MONTHLY EXPENSES AMOUNT Rent/mortgage Employment/wages (gross amount) Utilities Unemployment Phone Alimony/child support Food Pension or retirement income Insurance premiums Social Security Retirement Medical expenses Worker’s compensation Medication expenses Social Security Disability Income Car payment Supplemental Security Income Transportation FIP/TANF State Disability Assistance Other: Veteran’s Benefits Other: Other: Other: Other: Other: TOTAL: TOTAL: MONTHLY INCOME EXPENSES – Comments: EMPLOYMENT/DISABILITY Since last (re)assessment, there has been: New Need Continuing Need This is a: No changes Changes Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below.
Do you need assistance with your children’s HIV medical care/medications? Yes No What is your relationship with children? Do you have other dependents? Yes No # of dependents Ages # living with you If dependents do not live with you, where do they live? Do you need assistance in caring for adult dependents? Yes No What is your relationship with dependents? Comments: Finances and Benefits Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below. INCOME AND EXPENSES Do you have income? Yes No If yes, complete chart below: MONTHLY INCOME AMOUNT MONTHLY EXPENSES AMOUNT Employment/wages (gross amount) Rent/mortgage Unemployment Utilities Alimony/child support Phone Pension or retirement income Food Social Security Retirement Insurance premiums Worker’s compensation Medical expenses Social Security Disability Income Medication expenses Supplemental Security Income Car payment FIP/TANF Transportation State Disability Assistance Veteran’s Benefits Other: Other: Other: Other: Other: Other: TOTAL: TOTAL: MONTHLY INCOME – EXPENSES Comments: EMPLOYMENT/DISABILITY Since last (re)assessment, there has been: No changes Changes This is a: New Need Continuing Need Not a need If there are changes and/or this is a new/continuing need, then updates must be provided below.
ELECTRONIC_Standardized_Michigan_HIV_MCM_Reassessment_Pilot_Tool_2_2016_517966_7.docx