First Name / MI / Last Name
Check data quality option: ☐Full Name ☐Partial, street or code name ☐Client doesn’t know ☐Client refused
Maiden Name (if applicable) / Alias or any other names used
Social Security Number(SSN)
Check data quality option: ☐Full SSN ☐Approx. or partial SSN ☐Client doesn’t know ☐Client refused
U.S. Military Veteran / ☐Yes ☐No ☐Client doesn’t Know ☐Client Refused
Date Client Entered Project / Project Name
Household Relationship Information (select one) / ☐Couple with No Children
☐Couple (Parent & Friend) with Child(ren)
☐Foster Parent
☐Grandparent(s) &Child(ren)
☐Non-Custodial Caregivers / ☐Single Female Parent
☐Single Male Parent
☐Single Person
☐Two Parent Family
☐Other
Date of Birth (DOB) / ☐Full DOB ☐Approx. or partial DOB ☐Client doesn’t know ☐Client refused
Gender
(select one) / ☐Female
☐Male
☐Trans Female / ☐Trans Male
☐Gender Non-Conforming / ☐ Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White
☐Client doesn’t know / ☐Client refused
☐N/A
Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client doesn’t know ☐Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Health Insurance Information
Covered by Health Insurance / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Type
(Select all that apply) / Covered
Yes / Covered
No
Medicaid / ☐ / ☐ /
Medicare / ☐ / ☐ /
State Children’s Health Insurance Program / ☐ / ☐ /
Veteran’s Administration (VA) Medical Services / ☐ / ☐ /
Employer-Provided Health Insurance / ☐ / ☐ /
Health Insurance obtained through COBRA / ☐ / ☐ /
Private Pay Health Insurance / ☐ / ☐ /
State Health Insurance for Adults / ☐ / ☐ /
Indian Health Services Program / ☐ / ☐ /
Other ( Specify): / ☐ / ☐ /
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner / ☐ Head of Household’s other relation member
☐ Other: Non-relation member
☐ Client refused
Zip Code of Last Permanent Address / Client Location / ☐NE-500 BOS (Anywhere in Nebraska outside of Lincoln/Omaha)
☐NE-502 Lincoln
Living Situation: Residence the night before program admission, and length of stay at that residence (complete only 1 section A, B, or C)
A.
Literally Homeless / ☐ Place not meant for habitation
☐ Emergency Shelter, or hotel/motel paid for with emergency shelter voucher Shelter name:______
☐ Safe Haven
☐ Interim Housing(a housing situation where a chronically homeless person a unit reserved)
Length of stay in: ______days ApproximateDate Started:______
Number of times on the streets, in Emergency Shelter in the past three years including today: ______
Total number of months homeless on the street, in Emergency Shelter in the past three years:______
B.
Institutional Situation / ☐ Foster care home or foster care group home
☐ Hospital or other residential non-psychiatric medical facility
☐ Jail, prison or juvenile detention facility
☐ Long-term care facility or nursing home
☐ Psychiatric hospital or other psychiatric facility
☐ Substance abuse treatment facility or detox center
Length of stay: ______days More than 90 days: ☐ Yes ☐ No
On the night before, did you stay on the streets, in Emergency Shelter, or a Safe Haven? ☐ Yes ☐ No
Approximate Date Started:______
C.
Transitional & Permanent Housing Situation / ☐ Hotel or motel paid for without emergency shelter voucher
☐ Owned by client, no ongoing housing subsidy
☐ Owned by client, with ongoing housing subsidy
☐ Permanent housing (other than RRH) for formerly homeless persons
☐ Rental by client, no ongoing housing subsidy
☐ Rental by client, with VASH subsidy
☐ Rental by client, with GPD TIP subsidy
☐ Rental by client, with other ongoing housing subsidy (including RRH)
☐ Residential project or halfway house with no homeless criteria
☐ Staying or living in a family member's room, apartment or house
☐ Staying or living in a friend's room, apartment or house
☐ Transitional housing for homeless persons (including homeless youth)
Length of stay: ______days More than 7 days: ☐ Yes ☐ No
On the night before, did you stay on the streets, in Emergency Shelter, or a Safe Haven? ☐ Yes ☐ No
Approximate Date Started:______
Length of Time Homeless Status Documented? / ☐ Yes ☐ No
Income Information
Income from any source? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Total Monthly CASH income: Write in total $ amount and complete the table below Total Monthly Income: $______
Receives Income Sources / Yes / Monthly Amount $ / No / Not Collected
AABD (Aid to Aged, Blind & Disabled) / ☐ / $ / ☐ / ☐ /
Alimony or Other Spousal Support / ☐ / $ / ☐ / ☐ /
Child Support / ☐ / $ / ☐ / ☐ /
Contributions from other People / ☐ / $ / ☐ / ☐ /
Earned Income (from job) / ☐ / $ / ☐ / ☐ /
General Assistance / ☐ / $ / ☐ / ☐ /
Pension or retirement income from job / ☐ / $ / ☐ / ☐ /
Pension/Retirement / ☐ / $ / ☐ / ☐ /
Private Disability Insurance / ☐ / $ / ☐ / ☐ /
Retirement Income from Social Security / ☐ / $ / ☐ / ☐ /
Self Employment Wages / ☐ / $ / ☐ / ☐ /
SSA / ☐ / $ / ☐ / ☐ /
SSDI / ☐ / $ / ☐ / ☐ /
SSI / ☐ / $ / ☐ / ☐ /
Stipend / ☐ / $ / ☐ / ☐ /
Unemployment Insurance / ☐ / $ / ☐ / ☐ /
VA Non-service connected disability compensation / ☐ / $ / ☐ / ☐ /
VA service-connected disability compensation / ☐ / $ / ☐ / ☐ /
Worker’s Compensation / ☐ / $ / ☐ / ☐ /
Other (specify): / ☐ / $ / ☐ / ☐ /
Non-Cash Benefits Information
Non-cash benefits from any source / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Receives the following Non-cash Benefit Types: / Yes / Monthly Amount $ (if known) / No / Not Collected
Supplemental Nutrition Assistance Program (SNAP)(Food Stamps) / ☐ / $ / ☐ / ☐ /
Special Supplemental Nutrition for Women, infants, children(WIC) / ☐ / N/A / ☐ / ☐ /
TANF Child Care Services / ☐ / $ / ☐ / ☐ /
TANF Transportation services / ☐ / N/A / ☐ / ☐ /
Other TANF funded services / ☐ / N/A / ☐ / ☐ /
Other (specify): / ☐ / $ / ☐ / ☐ /
Health Insurance Information
Covered by Health Insurance / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Type
(Select all that apply) / Covered
Yes / Covered
No
Medicaid / ☐ / ☐ /
Medicare / ☐ / ☐ /
State Children’s Health Insurance Program / ☐ / ☐ /
Veteran’s Administration (VA) Medical Services / ☐ / ☐ /
Employer-Provided Health Insurance / ☐ / ☐ /
Health Insurance obtained through COBRA / ☐ / ☐ /
Private Pay Health Insurance / ☐ / ☐ /
State Health Insurance for Adults / ☐ / ☐ /
Indian Health Services Program / ☐ / ☐ /
Other ( Specify): / ☐ / ☐ /
As a child, were you ever in Foster Care or are you now? / ☐ Yes ☐ No
Domestic violence victim/survivor? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
If yes for Domestic Violence victim/survivor, when experience occurred / ☐Within the past three months
☐Three to six months ago
☐From six to twelve months ago / ☐More than a year ago
☐Client doesn’t know
☐Client refused
If yes for Domestic Violence Victim/Survivor, are you currently fleeing? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Highest level of education attained / ☐No schooling completed
☐Nursery school to 4th grade
☐5th or 6th grade
☐7th grade or 8th grade
☐9th grade
☐10th grade / ☐11th grade
☐ 12th grade, no diploma
☐ Some High School
☐High school diploma
☐GED
☐Post-Secondary School / ☐Some College
☐ Some Technical School
☐ Graduate Degree
☐ Technical School Certification / ☐Client refused
☐ Client Doesn’t Know
Client’s Residence/Last Permanent Address
Street Address
City / State / Zip code
County of Current Residence / County of Legal Residence
Home Phone Number / Cell Phone / Work
Child #1–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type
Child #2–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type
Child #3–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type
Child #4–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type
Child #5–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type
Child #6–Please complete for any children in your household (1 child per page)
First Name / MI / Last Name
Social Security Number(SSN)
Date of Birth (DOB) / Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse /  /  /  /  /  / 
Drug Abuse /  /  /  /  /  / 
Both alcohol and drug abuse /  /  /  /  /  / 
Chronic Health Condition /  /  /  /  /  / 
Developmental Disability /  /  /  /  /  / 
HIV/AIDs /  /  /  /  /  / 
Mental Health Problem /  /  /  /  /  / 
Physical Disability /  /  /  /  /  / 
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Covered by Health Insurance I.E. Medicaid, etc. / ☐ Yes ☐ No If yes, enter type

1 UNL-Center on Children, Families, and the Law (CCFL) & Community Services Management Information System (CS-MIS) 10/17

I ______understand information about me and/or my dependents listed below is entered into a database system called ServicePoint. This system helps to better understand homelessness, to improve service delivery and to evaluate the effectiveness of services provided. Participation in data collection is a critical component of our community’s ability to provide the most effective services and housing possible. The information that is collected is protected by limiting access to the database and limiting what information may be shared. Access to the data and sharing of the data is in compliance with the standards set by the federal, state and local regulations governing confidentially of client records. Every person and agency that is authorized to read or enter information into the system has signed an agreement to maintain the security and confidentiality of the information.

By signing this form, I authorize the following:

The information collected by this agency will be included in ServicePoint and only partner agencies, which have entered into an HMIS Agency Participation Agreement, may be used to:

  • Produce a client profile at intake that will be shared with collaborating agencies
  • Produce aggregate level reports regarding use of services
  • Track individual program-level outcomes
  • Identify unfilled service needs and plan for enhancements
  • Allocate resources among agencies engaged in services

By signing this form, I authorize the following:

I authorize the partner agencies and their representatives to share basic information regarding my family members listed below and/or me. I understand that this information is for the purpose of assessing my/our needs for housing, utility assistance, food, counseling and/or other services.

The information may consist of the following PPI (Personal Protected Information):

  • Name
/
  • Homeless History
/
  • Disabling Condition

  • Date of Birth
/
  • Family Composition
/
  • Photo (if applicable)

  • Social Security Number
/
  • Income/Non-cash
/
  • Housing information

  • Gender
/
  • Veteran Status
/
  • Health Insurance Status

  • Ethnicity and Race
/
  • Domestic Violence
/
  • Client Location

  • Residence Prior to Project Entry
/
  • VI-SPDAT

I Understand That:

The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality polices used by the HMIS partner agencies

Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information.

The release of my information does not guarantee that I will receive assistance; my refusal to authorize the use of my information does not disqualify me from receiving assistance.

My records are protected by federal, state, and local regulations governing confidentially of client records and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

This authorization will remain in effect until I revoke it in writing, and I may revoke authorization at any time, if I revoke my authorization, all information about me already in the database will remain.