Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member.

Transcription

1 Agency Name: CLARITY HMIS: HUD-COC INTAKE FORM Use block letters for text and mark appropriate boxes with an X. Complete a separate form for each household member. PROGRAM ENTRY DATE [All Clients] - - Month Day Year RELATIONSHIP TO HEAD OF HOUSEHOLD [All Clients] Husband Grandparent Father Grandchild Significant Other Mother Aunt Other Sister Uncle Wife Brother Niece Daughter Roommate Nephew Son SOCIAL SECURITY NUMBER [All Clients] - - QUALITY OF SOCIAL SECURITY Full SSN reported Approximate or partial SSN reported CURRENT NAME [All Clients] Last First Middle N/A Suffix QUALITY OF CURRENT NAME [All Clients] Full name reported Partial, street name, or code name reported DATE OF BIRTH [All Clients] - - Age: Month Day Year QUALITY OF DATE OF BIRTH Full DOB reported Approximate or partial DOB reported

2 GENDER [All Clients] Female Male Transgender male to female Transgender female to male If Other Specify: Other CONTACT INFORMATION [Optional] Phone Number - - Current Address (if applicable) Street City State Zip Code RACE [All Clients] American Indian or Alaskan Native Asian Black/African American Client Refused ETHNICITY [All Clients] n-hispanic n-latino Hispanic/Latino Hawaiian or Other Pacific Islander White/Caucasian Client does not know Data t Collected VETERAN STATUS [All Adults] IF YES TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II Theater of Operations: Korean War

3 Theater of Operations: Vietnam War Theater of Operations: Persian Gulf War (Desert Storm) Theater of Operations: Afghanistan (Operation Enduring Freedom) Theater of Operations: Iraq (Operation Iraqi Freedom) Theater of Operations: Iraq (Operation New Dawn) Theater of Operations: Other peace-keeping operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) Branch of the Military Army Coast Guard Air Force Navy Marines Discharge Status Honorable Dishonorable General under honorable conditions Uncharacterized Other than honorable conditions (OTH) Bad Conduct HOUSING STATUS AT ENTRY [Head of Households and Adults] Homeless Fleeing domestic violence At imminent risk of losing housing At-risk of homelessness Homeless only under other federal statutes Stably housed

4 RESIDENCE PRIOR TO PROGRAM ENTRY [Head of Households and Adults] Emergency shelter, including hotel or motel paid for Rental by client, with DPD TIP subsidy w/ emergency shelter voucher Foster care home or group home Rental by client, with other ongoing Housing subsidy Hospital or other residential non- Rental by client, with VASH subsidy psychiatric medical facility Hotel or motel paid for without emergency Shelter voucher Residential project or halfway house With no homeless criteria Jail, prison or juvenile detention facility Safe Haven Long-term care facility or nursing home Staying or living in a family member s Room, apartment or house Owned by client, no on-going housing subsidy Staying or living in a friend s room, apartment or house Owned by client, with ongoing housing subsidy Substance abuse treatment facility or detox center Permanent housing for formerly homeless persons (ex. CoC project, HUD legacy) Transitional housing for homeless persons (including homeless youth) Place not meant for habitation Other Psychiatric hospital or other psychiatric facility Rental by client, no ongoing housing subsidy Specify Other LENGTH OF STAY IN PREVIOUS PLACE One day or less One to three months Two days to one week More than three months, More than one week, but less than one month One year or longer LENGTH OF TIME ON STREET, EMERGENCY SHELTER, OR SAFE HAVEN [Head of Households and Adults] CONTINUOUSLY HOMELESS FOR AT LEAST ONE YEAR TIMES HOMLESS IN PAST THREE YEARS 0 4 or more NUMBER OF MONTHS HOMELESS IN PAST THREE YEARS 0-12 months (specify number of months): If more than 12 months, number of years: Length of time homeless documented?

5 IN PERMANENT HOUSING [RRH PROGRAMS ONLY - All Adults] Date of Move-In: / / DISABLING CONDITION [All Adults] PHYSICAL DISABILITY [All Clients] IF YES TO PHYSICAL DISABILITY SPECIFY Receiving services for physical disability Long-term physical disability Documentation of the disability and severity on file DEVELOPMENTAL DISABILITY [All Clients] IF YES TO DEVELOPMENTAL DISABILITY SPECIFY Currently receiving services for developmental disability Long-term developmental disability Documentation of the disability and severity on file CHRONIC HEALTH CONDITION [All Clients] IF YES TO CHRONIC HEALTH CONDITION SPECIFY Currently receiving services/treatment for this condition Long-term chronic health condition Documentation of the disability and severity on file

6 HIV-AIDS [All Clients] IF YES TO HIV-AIDS SPECIFY Currently receiving services/treatment for this condition Expected to substantially impair independence Documentation of the disability and severity on file MENTAL HEALTH PROBLEMS [All Clients] IF YES TO MENTAL HEALTH PROBLEMS SPECIFY Currently receiving services/treatment for this condition Long-term mental health problems Documentation of the disability and severity on file SUBSTANCE ABUSE PROBLEMS [All Clients] Both alcohol and drug abuse Alcohol abuse Drug abuse IF ALCOHOL ABUSE DRUG ABUSE OR BOTH ALCOHOL AND DRUG ABUSE SPECIFY Currently receiving services/treatment for this condition Long-term substance abuse problem Documentation of the disability and severity on file

7 DOMESTIC VIOLENCE [Head of Households and Adults] IF YES TO DOMESTIC VIOLENCE LAST OCCURANE Within the past three months Three to six months ago (excluding six months exactly) Six months to one year ago (excluding one year exactly) One year ago or more INCOME FROM ANY SOURCE [Head of Households and Adults] IF YES TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source Amount Earned Income Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability Income (SSDI) VA service-connected disability comp. VA non-service connected Disability pension Private disability insurance Worker s compensation Total monthly amount: TANF (Temporary Assistance to Needy Families) General Assistance (GA) Retirement income from Social Security Pension or retirement income from former job Child support Alimony and other spousal support Other source Specify Other RECEIVING NON-CASH BENEFITS [Head of Households and Adults] IF YES TO NON-CASH BENEFITS INDICATE ALL SOURCES THAT APPLY Special Supp. Nutrition Program for Women, infants and Children (SNAP) Other TANF Benefit WIC Section 8 TANF Childcare Other Source TANF Transportation Temporary Rental Assistance Specify Other

8 COVERED BY HEALTH INSURANCE [All Clients] IF YES TO HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS MEDICAID Employer Provided MEDICARE Obtained through COBRA SCHIP Private Pay Health Insurance VA Medical State Health Insurance for Adults CURRENTLY ENROLLED IN SCHOOL [All Clients] NAME OF SCHOOL [If Applicable] IF YES TO CURRENTLY ENROLLED IN SCHOOL IS PROGRAM VOCATIONAL TRAINING OR APPRENTICESHIP HIGHEST LEVEL OF EDUCATION COMPLETED [All Clients] Schooling Grade 10 GED Nursery to Grade 4 Grade 11 Grades 5-6 Grade 12, Diploma Grades 7-8 High School Diploma Grade 9 Post Secondary School Signature of applicant stating all information is true and correct Date