Budget Worksheet
Please complete each applicable line with the best estimate of your household income and expenses. If a line does not apply to you, please enter 0. When finished, review the worksheet and submit it to your therapist.
| Number of employed individuals contributing to the household: | |
| Number of dependents under age 18: | |
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Total average monthly household income from all sources:
"Household" means everyone living under the same roof and/or sharing expenses.
"All sources" means wages, pensions, investments, government payments (disability, TANF, Social Security, etc.) real estate, rent income, child support, spousal support, trust funds, etc.
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| Monthly household fixed living expenses: | |
| Rent, or mortgage | |
| Car payments and insurance | |
| Utilities (average) | |
| School Tuition | |
| Food (average) | |
| Client paid health insurance | |
| Credit cards | |
| Household and personal hygiene | |
| Unusual or extraordinary expenses: | |
| Childcare for disabled minor | |
| Education for special needs child | |
| Unusual medical expenses | |
| Other: |