VA SSVF Client Update v2 (10-27-15)
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Client ID: ______
Update Date: ______
Client Location: KY-501
- Do you have an update to your income?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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1a. If yes, please mark source and amount per month:
VA SSVF Client Update v2 (10-27-15)
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□Earned income (employment only) $______
□Unemployment Insurance $______
□Supplemental Security Income (SSI) $______
□Social Security Disability Income (SSDI)$______
□VA Service-Connected Disability Compensation $______
□VA Non-Service-Connected Disability Pension $______
□Private Disability Insurance $______
□Worker’s Compensation $______
□Temporary Assistance for Needy Families (TANF)$______
□General Assistance (GA) $______
□Retirement from Social Security$______
□Pension or Retirement Income from Another Job $______
□Child Support $______
□Alimony and other spousal support $______
□Other source: ______$______
______
- Do you have an update to non-cash benefits?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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2a. If yes, please mark source and amount per month, if applicable:
□Supplemental Nutrition Assistance Program (SNAP) – Food Stamps$______
□Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)$______
□TANF Child Care Services$______
□TANF transportation services$______
□Other TANF-funded services$______
□Section 8, public housing, or other ongoing rental assistance$______
□Temporary rental assistance$______
□Other source ______$______
______
- Do you have an update to your health insurance coverage?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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3a. If yes, please select the type of health insurance:
□Employer-Provided Health Insurance
□Medicaid
□Medicare
□State Children’s Health Insurance Program
□Veterans Administration (VA) Medical Services
□Health Insurance obtained through COBRA
□Private Pay Health Insurance
□State Health Insurance for Adults
3b. If no, please indicate the current stage of enrollment:
□Applied, decision pending
□Applied, client not eligible
□Client has not applied
□Insurance type N/A for this client
□Client Doesn’t Know
Client Refused
______
- Have you had a change in the type of disability or document, receiving services?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
VA SSVF Client Update v2 (10-27-15)
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**If yes, please select type of disability and complete extra questions:
4a. Physical Disability
-Is this Physical Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
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□Yes
□No
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
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4b. Developmental Disability (must have developed prior to age 22)
-Is this Developmental Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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4c. Chronic Health Condition
-Is this Chronic Health Condition expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
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□Yes
□No
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
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4d. HIV/AIDS
-Does HIV/AIDS substantially impair your ability to live independently?
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Is the documentation of disability and severity on file or available for case worker?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
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4e. Mental Health Problem
-Is this Mental Health Problem expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Is the documentation of disability and severity on file or available for case worker?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
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-How was this Mental Health Problem confirmed?
□Unconfirmed: presumptive or self-reported
□Confirmed through assessment and clinical evaluation
□Confirmed by prior evaluation or clinical records
-If this is considered a Serious Mental Illness (SMI), how was that confirmed?
□Not Considered SMI
□Unconfirmed: presumptive or self-reported
□Confirmed through assessment and clinical evaluation
□Confirmed by prior evaluation or clinical records
4f. Substance Abuse
□Alcohol Abuse
□Drug Abuse
□Both Alcohol and Drug Abuse
-Is this Substance Abuse Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
VA SSVF Client Update v2 (10-27-15)
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-Are you currently receiving services or treatment for this condition?
VA SSVF Client Update v2 (10-27-15)
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□Yes
□No
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-How was this Substance Abuse Disability confirmed?
□Unconfirmed: presumptive or self-reported
□Confirmed through assessment and clinical evaluation
□Confirmed by prior evaluation or clinical record