Main concern to organize Mood, anxiety, grief, or stress Loneliness, isolation, or loss of routine Substance use or medication-use concern Caregiver strain or emotional support need Not sure what fits
Urgency level Routine planning, no immediate safety concern Symptoms or safety concerns are worsening After ER, hospital, rehab, or crisis contact Immediate safety concern may be present Not sure
Likely care path to ask about Primary care or current clinician Therapy or counseling Psychiatry or medication management Intensive outpatient or partial hospitalization Finding an in-network provider
Current coverage Original Medicare Medicare Advantage Medicare plus Medicaid or other low-income help VA, employer, retiree, or other coverage Not Medicare or not sure
Provider access status Provider search not started Providers are hard to find On a waitlist or long delay Service, provider, or claim problem Connected with a provider
Appointment status Not scheduled yet Appointment is scheduled Appointment was missed or delayed Recent visit needs follow-up Not sure
Cost or billing question Costs not reviewed yet Copay, deductible, or coinsurance question Bill, EOB, or denial needs review Medication cost or pharmacy question Low-income help or community clinic question
Who is coordinating? Older adult is coordinating Spouse or partner Adult child or family helper Long-distance caregiver Paid caregiver, agency, or facility staff
Privacy and permission setup Permissions not reviewed yet Release or portal proxy may be needed Permission setup appears ready Privacy, coercion, or family conflict concern Not sure
Next contact to prepare for Clinician or clinic office Medicare, Medicare Advantage, or drug plan SHIP Medicare counselor Area Agency on Aging or local support 988, crisis line, or urgent support
Use this to prepare coverage, provider, appointment, and support questions.
Do not enter names, addresses, birth dates, diagnoses, Medicare numbers, Social Security numbers, account numbers, medicine names, passwords, trauma details, substance-use details, or private medical records. Keep personal notes in a secure private folder.
This planner is educational and organizational only. It is not medical, mental-health, crisis, substance-use, legal, insurance, benefits, financial, or emergency advice. If there is immediate danger or thoughts of self-harm, call emergency services or call or text 988 in the United States.
Official references:
Medicare mental health and substance use disorder coverage ,
Medicare outpatient mental health care ,
Medicare mental health benefits booklet ,
NIA mental and emotional health ,
ACL caregiver support ,
988 Lifeline .
