Serving Honolulu, Maui, Kauai and Hawaii Counties Outreach Contact/Encounter Form

Serving Honolulu, Maui, Kauai and Hawaii Counties Outreach Contact/Encounter Form

Last Name* / First Name*
Encounter Date* / Alias
Project (Program)*
Case Worker / Last 4 digits of SSN
Service Type: (Self Populates in HMIS)
·  Use this form for recording services and referrals provided during encounter with client.
·  Use Outreach Entry/Assessment form for new clients and for updating client information (health, disability, length of homelessness, etc.)
Location Type* ☐ Place Not Meant for Habitation / ☐ Service Setting, Non-Residential / ☐ Service Setting, Residential

PIT Region

Adult OUTREACH Contact/Encounter Form V.1 – October 2016 (*Required fields) Page 2 of 2

C. Peraro Consulting, LLC – HMIS System Administrator for the State of Hawaii

Serving Honolulu, Maui, Kauai and Hawaii Counties Outreach Contact/Encounter Form

☐ Oahu – Region 1: Downtown Honolulu: Salt Lake to Piikoi Street

☐ Oahu – Region 2: East Honolulu: Piikoi Street to Hawaii Kai, including Waikiki

☐ Oahu – Region 3: Ewa: Aiea to Kapolei

☐ Oahu – Region 4: Kaneohe to Waimanalo

☐ Oahu – Region 5: Wahiawa to North Shore

☐ Oahu – Region 6: Upper Windward: Kahaluu to Kahuku

☐ Oahu – Region 7: Waianae Coast

☐ Maui – Region 1: Central Maui

☐ Maui – Region 2: Lower Waiehu

☐ Maui – Region 3: Up Country

☐ Maui – Region 4: Lahaina

☐ Maui – Region 5: Kihei

☐ Maui – Region 6: Hana

☐ Kauai - Region 1: West

☐ Kauai - Region 2: South

☐ Kauai - Region 3: South Central

☐ Kauai - Region 4: East

☐ Kauai - Region 5: North

☐ Hawaii - Region 1: Kohala

☐ Hawaii - Region 2: Honokaa

☐ Hawaii - Region 3: Laupahoehoe

☐ Hawaii - Region 4: Hilo

☐ Hawaii - Region 5: Waiakea

☐ Hawaii - Region 6: Keaau

☐ Hawaii - Region 7: Pahoa

☐ Hawaii - Region 8: Kau

☐ Hawaii - Region 9: Konawaena

☐ Hawaii - Region 10: Kealakehe

Adult OUTREACH Contact/Encounter Form V.1 – October 2016 (*Required fields) Page 2 of 2

C. Peraro Consulting, LLC – HMIS System Administrator for the State of Hawaii

Serving Honolulu, Maui, Kauai and Hawaii Counties Outreach Contact/Encounter Form

Adult OUTREACH Contact/Encounter Form V.1 – October 2016 (*Required fields) Page 2 of 2

C. Peraro Consulting, LLC – HMIS System Administrator for the State of Hawaii

Serving Honolulu, Maui, Kauai and Hawaii Counties Outreach Contact/Encounter Form

Location of Encounter*

Where did you sleep last night?*

Encounter Zip Code*

Milestones/Outcomes Achieved During this Encounter:

☐ Attended psychiatric appointment(s) / ☐ Entered vocational training program
☐ Began case management services / ☐ Established SSI/SSDI
☐ Began domestic violence services / ☐ Moved into emergency housing
☐ Began medications for mental illness / ☐ Moved into permanent housing
☐ Benefits: Obtained GA/TANF / ☐ Moved into permanent supportive housing
☐ Benefits: Obtained medical insurance / ☐ Moved into transitional housing
☐ Benefits: Obtained SNAP (Food Stamps) / ☐ Obtained employment
☐ Birth certificate/ID obtained / ☐ Other:
☐ Entered detox/substance abuse treatment

Notes:

Services and Referrals Provided During Contact/Encounter

SERVICES

A. Services Provided ☐ Face-To-Face ☐ Internet ☐ Phone ☐ Other

☐ Benefits application assistance / ☐ Food/meal provided / ☐ Primary healthcare services
☐ Budgeting assistance / ☐ Housing placement assistance / ☐ Representative payee
☐ Client Advocacy / ☐ Hygiene supplies / ☐ Translation services
☐ Crisis management services / ☐ ID assistance given / ☐ Transportation
☐ Employment assistance / ☐ Mail pick-up Service / ☐ Other:

B. Counseling Services Provided: ☐ Face-To-Face ☐ Internet ☐ Phone ☐ Other

☐ Crisis intervention counseling / ☐ Family counseling / ☐ Shelter/housing counseling
☐ Domestic violence counseling / ☐ Health education/life-style / ☐ Substance use treatment - service
☐ Employment/vocational counseling / ☐ Mental health services / ☐ Other:

REFERRALS

C. Health Referrals:

☐ Acute/urgent care / ☐ Family planning / ☐ Substance use treatment
☐ AMHD eligibility screening / ☐ HIV/Hepatitis support / ☐ TB screening
☐ Crisis intervention / ☐ Mental health professional / ☐ Other:
☐ Dental/vision / ☐ Primary health services

D. Social Services Referrals:

☐ Clothing / ☐ GA/TANF benefits / ☐ Social security card
☐ Education/Vocational training / ☐ ID assistance / ☐ Social security disability (SSDI)
☐ Emergency shelter / ☐ Legal / ☐ Transitional shelter
☐ Employment / ☐ Medical benefits/insurance / ☐ Transportation/bus pass
☐ Food/meal / ☐ Permanent housing / ☐ Veterans assistance
☐ Other:

Notes:

Adult OUTREACH Contact/Encounter Form V.1 – October 2016 (*Required fields) Page 2 of 2

C. Peraro Consulting, LLC – HMIS System Administrator for the State of Hawaii