CT HMIS PATH (Outreach) Exit

CT HMIS PATH (Outreach) Exit

Revised 10/16/2017

Applicant (Head of Household) Information:

First Name: ______Last Name: ______Client ID#: ______

Project Exit Date: ______Case Manager Assigned to Discharge: ______

CT Statewide PATH Discharge Form (ver2017.10.16)

Destination Type:

¨ Emergency shelter or hotel paid w/ voucher

¨ Transitional housing for homeless persons (including homeless youth)

¨Permanent housing (there than RRH) for formerly homeless persons

¨ Psychiatric hospitalor other psychiatric facility

¨Substance abuse treatment facility or detox center

¨ Hospital (non-psychiatric)

¨ Jail,prison, or juvenile detention facility

¨ Rental, no subsidy

¨ Owned, no subsidy

¨ With family, temporary tenure

¨ With friends, temporary tenure

¨ Hotel / motel w/o emergency voucher

¨ Foster care or foster care group home

¨ Place not meant for human habitation

¨ Safe Haven

¨ Rental, VASH subsidy

¨ Rental, (non-VASH) housing subsidy

¨Owned, with subsidy

¨ With family, permanent tenure

¨ With friends, permanent tenure

¨ Deceased

¨ Long-term care facility or nursing Home

¨ Moved from one HOPWA funded project to HOPWA PH

¨ Moved from one HOPWA funded project to HOPWA TH

¨ Rental by client, with GPD TIP housing subsidy

¨ Residential project or halfway house with no homeless criteria

¨ No Exit Interview completed

¨Client doesn't know

¨ Client refused

¨ Other

CT Statewide PATH Discharge Form (ver2017.10.16)

If Other, please explain: ______

Non-Cash Benefit from any source? ¨ No ¨ Yes ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected

Head of Household
YES / NO
(SNAP) Food Stamps
Special Supplemental Nutrition Program for WIC
TANF Child Care Services
TANF Transportation
Other TANF Funded Services
Client Doesn't know
Client Refused
Other (Please Specify):

Covered by Health Insurance: ¨ No ¨ Yes ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected

Connection with SOAR: ¨ No ¨ Yes ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected

Disabling Conditions (All Clients):

Head of Household
Disabling Condition (All Adults)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected / N/A
Physical Disability (All Clients)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
Developmental Disability (All Clients)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to substantially impair ability to live independently? No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
Chronic Health Condition (All Clients)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
HIV/AIDS (All Clients)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to substantially impair ability to live independently? No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
Mental Health Problem (All Clients)
No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? No, Yes, Client Doesn’t Know, Client Refused, Data Not Collected
Substance Abuse (All Clients)
No, Alcohol Abuse, Drug Abuse, Both Alcohol and Drug, Client Doesn’t Know, Client Refused, Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused
Head of Household / HH Member 2 / Member 3 / Member 4 / Member 5
YES / NO* / YES / NO* / YES / NO* / YES / NO* / YES / NO*
Medicaid
Medicare
State Children’s Health Insurance Program
Veterans Administration (VA) Medical Services
Employer-Provided Health Insurance
Health Insurance Obtained through COBRA
State Health Insurance for Adults
Private Pay Health Insurance
Indian Health Services Program
Other(specify): ______

Health Insurance (All Clients):

Revised: 10.16.2017

Income

Income received from any source (HOH and Adults only)? ¨ No ¨ Yes ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected

*Note: Income received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household.

Head of Household
Income Type / Monthly Amount
Unemployment Insurance
Earned Income (i.e. Employment income)
Supplemental Security income (SSI)
Social Security Disability Income (SSDI)
VA Service Connected Disability Compensation
Private Disability Insurance
Temporary Assistance for Needy Families (TANF)
General Assistance (GA)
Retirement Income and Social Security
VA Non-Service-Connected Disability Pension
Pension or retirement income from another job
Child Support
Alimony or other spousal support
Worker's Compensation
Other Source
Client Income Total:

Revised: 10.16.2017

Date of Status Determination: ______

Client became enrolled in PATH: ¨ Yes ¨ No

DMHAS Specific Question (*= required information):

*Discharge Reason

¨AWOL for Inpatient only ¨Death ¨Evaluation Only ¨Incarcerated

¨Inpatient Discharge for Inpatient Medical Tx ¨Client Discontinued Tx ¨AMA

¨Left Against Advice ¨Moved out of area ¨Non-compliance with rules ¨Recovery Plan Completed

¨Released by Court ¨Discharged to New Service (Facility Concurs)

¨Other ¨Unknown

Co-Occurring Assessment Date: ______

* Employment Status:

Revised: 10.16.2017

¨ Employed full time (in competitive employment)

¨ Employed part time (in competitive employment)

¨ Unemployed (looking for work in the past 30 days, or on a layoff)

¨ Paid but non-competitive work (transitional employment programs)

¨ Paid but non-competitive work (work inside the clubhouse or treatment agency, mobile work crews and consumer-run businesses)

¨ Not in Labor Force: student enrolled in a school or job-training program

¨ Not in Labor Force: homemaker

¨ Not in Labor Force: retired

¨ Not in Labor Force: SSI SSDI

¨ Not in Labor Force: Inmate of institution.

¨ Not in Labor Force: other reason

¨ Other

¨ Unknown

Revised: 10.16.2017

*Highest Grade Completed:

Revised: 10.16.2017

¨ 1

¨ 2

¨ 3

¨ 4

¨ 5

¨ 6

¨ 7

¨ 8

¨ 9

¨ 10

¨ 11

¨ 12

¨ 13

¨ 14

¨ 15

¨ 16

¨ 17

¨ 18

¨ 19

¨ 20

¨ 21

¨ Unknown

Revised: 10.16.2017

Persons Dependent on Income:

Revised: 10.16.2017

¨ 1

¨ 2

¨ 3

¨ 4

¨ 5

¨ 6

¨ 7

¨ 8

¨ 9

¨ 10

¨ 11

¨ 12

¨ 13

¨ 14

¨ 15

Revised: 10.16.2017

Minors Dependent on Income:

Revised: 10.16.2017

¨ 1

¨ 2

¨ 3

¨ 4

¨ 5

¨ 6

¨ 7

¨ 8

¨ 9

¨ 10

¨ 11

¨ 12

¨ 13

¨ 14

¨ 15

Revised: 10.16.2017

*Principle Income Source:

Revised: 10.16.2017

¨ Disability

¨ None

¨ Other

¨ Public Assistance

¨ Retirement

¨ Salary

¨ Unknown

Revised: 10.16.2017

*Living situation at time of episodic assessment:

Revised: 10.16.2017

¨ Private residence, client owns or holds lease

¨ Private residence, friend or relative owns the residence or holds lease

¨ Single Room Occupancy (Hotel, YMCA, Rooming House)

¨ Private residence, Community agency owns or holds lease

¨ Residential Care Home/ Board and Care

¨ Congregate residential care (24-hour supervision, group setting, services focus on MH, SA, &/or MR issues, Recovery House.)

¨ Crisis / Respite Bed

¨ Skilled Nursing Facility/Intermediate Care Facility /Nursing Home

¨ Psychiatric/SA/Medical Inpatient.

¨ Correctional Facility

¨ Homeless Shelter,

¨ Homeless (including on street),

¨ Other,

¨ Unknown

Revised: 10.16.2017

Was Client Homeless in Last Six Months: ¨ Yes ¨ No ¨ Unknown

Number of Days in the Last 30 that the client lived in a Controlled Environment? (0 – 30) ______

Enter a value between 0 and 30 to represent the number of days in a controlled environment

*Number of arrests in last 30 days: (0 – 30) ______

Enter a value between 0 and 30 to represent the number of arrests; if unknown then write in Unknown

*Social support from family and/or friends in last 30: ¨ Yes ¨ No ¨ Unknown

Mental Health Diagnosis Assessment

Please provide ALL the ICD 10 Codes if Available and the Diagnosis:

AXIS I
AXIS I
AXIS I
AXIS II
AXIS II
AXIS III
AXIS III
AXIS III
AXIS IV
AXIS IV
AXIS IV
AXIS V / (GAF)

DSM Summary

Target symptoms being addressed: ______

When under stress this client may: ______

If substance user, has client used in past 6 months? ¨ Yes ¨ No

The best way to respond: ______

Date last used substance: ______

Current risk behaviors in last 6 months: ______

Substance Abuse:

Currently Using: ¨ Yes ¨ No

Frequency of use:

¨ Daily ¨ Once or Twice a Week

¨ Weekly ¨ Monthly ¨ Less than Monthly

Currently in Treatment: ¨ Yes ¨ No

Last Treatment Date: ______

Sponsor Information:

First Names: ______Last Names: ______

Longest Time abstinent: Enter the numeric value and then select the term i.e. days, weeks, months, years

Longest Time Free: ______(number)

Measure of Longest Time Free: ¨ Day(s) ¨ Week(s) ¨ Month(s) ¨ Year(s)

Drug Information:

Primary Drug of Choice / Secondary Drug of Choice / Tertiary Drug of Choice / Forth Drug of Choice / Fifth Drug of Choice
None
Amphetamines
Alcohol
Barbiturates
Benzodiazepines
Cocaine
Crack
Hallucinogens: LSD, DMS, STP, etc
Heroin
Inhalants
Marijuana, Hashish, THC
Methamphetamines
Non-Prescriptive Methadone
Other Opiates and Synthetics
Other Sedatives or Hypnotics
Other Stimulants
Over-the-Counter
PCP
Tranquilizers
Other
Unknown

Revised: 01.11.2016 10 of 4