HMIS Standard Intake Form–3.917AEffective 10/01/2016

Use for ES, SH, or SO projects. This form is NOTto be used for PH, TH or SSO, PREV, or any other project.

Project Name:______Entry:Svcpt# EntryType:

First:Middle:

Last:Suffix: Alias:

Social Security Number:

Page 1 of 3

FullSSN / Approximate or PartialSSN
Client doesn’tknow / Clientrefused
Household Information
Singleadult,
no children / Female single parent / Male singleparent / Couple with
no children
Two parentfamily with children / Couple (parent and friend) andchildren / Foster parent(s) andchildren / Grandparent(s) andchildren

Non-custodialcaregiver(s) Other:

Relationship to Head of Household:
Self (Head ofHousehold) / HoH’s child / HoH’s spouse orpartner
HoH’s other relationmember / Other: non-relationmember


Domestic Violence
Are you, or have you been a survivor of domestic or intimate partner violence?
No / Yes
Client doesn’tknow / Clientrefused
If YES, how long ago did you have this experience?
Within the past 3months / 1 year agoormore
3 to 6 monthsago / 6 months to 1 yearago
Client doesn’tknow / Clientrefused
If Yes , are you currently fleeing ?
No / Yes
Client doesn’tknow / Clientrefused

Ever in foster care? Yes No

Zip code of last permanent address:

HMIS Standard Intake Form –3.917A Page 2 of 3

Client’s Living Situation (Immediately) Prior to Project Entry

Literally Homeless Situation / Institutional Situation / Transitional/Permanent Housing Situation / Don’t Know/ Refused
☐ Place not meant for habitation (e.g. a vehicle, abandoned building, bus/train/subway station, airport, anywhere outside).
☐ Emergency shelter, including hotel or motel paid for with emergency shelter voucher
☐ Safe Haven
☐ Interim Housing (e.g. client applied for permanent housing and a unit/voucher has been reserved but client is not able to move in immediately). / ☐ Foster care home or foster 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 / ☐ 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 for formerly homeless persons (such as CoC Project)
☐ Rental by client, no ongoing housing subsidy
☐ Rental by client, with VASH housing subsidy
☐ Rental by client, with GPD TIP subsidy
☐ Rental by client with other ongoing housing subsidy
☐ 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) / ☐ Client doesn’t know
☐ Client refused
Length of Stay in Prior Living Situation?
☐ One night or less
☐ Two to six nights
☐ One week or more but less than one month / ☐One month or more but less than 90 days
☐90 days or more but less than one year
☐One year or longer / ☐Client doesn’t know
☐Client refused


HMIS Standard Intake Form–3.917A

Page 3 of 3

Income
No/None atall / Yes (Identify source andamounts)
Client doesn’tknow / Clientrefused
Source: / Amount:
Earned income (i.e., employmentincome) / $.00
UnemploymentInsurance / $.00
Supplemental Security Income(SSI) / $.00
Social Security Disability Income(SSDI) / $.00
Retirement Income from SocialSecurity / $.00
VA Service-Connected DisabilityCompensation / $.00
VA Non-Service-Connected DisabilityPension / $.00
Worker’sCompensation / $.00
Temporary Assistance for Needy Families(TANF) / $.00
General Assistance(GA) / $.00
Private disabilityInsurance / $.00
Pension or retirement income from a formerjob / $.00
ChildSupport / $.00
Alimony or other spousalsupport / $.00
Othersource: / $.00
Total Monthly Income: / $

Disability

Do you have a physical, mental or emotional impairment, a post-traumatic stress disorder, or brain injury; a developmental disability, HIV/AIDS, or a diagnosable substance abuse problem?

Client refused


Physical / 
Mental Health / 
Chronic Health Condition / Alcohol
Drugs
Both / 
Developmental / 
HIV/AIDS
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently: / Yes / Yes / Yes / Yes / N/A / N/A
Expected to substan- tially impair ability to live independently: / N/A / N/A / N/A / N/A / Yes / Yes
Documentation of the disability and severity on file: / Yes / Yes / Yes / Yes / Yes / Yes
Currently receiving services/treatment for this disability: / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused
Staff Completing (Printed Name): / Date: