Contact for any questions regarding documents or collection practices.

HMIS Individual Exit (10-01-2016)

Legal First Name: Legal Middle Name:

Legal Last Name: Suffix: ______

Program Exit

Destination: (choose one):
qDeceased / q Rental by client, with VASH Housing Subsidy
q Emergency shelter, including hotel/motel paid for with emergency shelter voucher / q Rental by client, with GPD TIP subsidy
qFoster care home or foster care group home / q Rental by client, with other ongoing housing subsidy
q Hospital or other residential non-psychiatric medical facility / qResidential project or halfway house with no homeless criteria
q Hotel or motel paid for without an emergency shelter voucher / q Safe Haven
q Jail, prison or other juvenile detention facility / q Staying or Living with Family, permanent tenure
q Long-term care facility or nursing home / q Staying or Living with Family, temporary tenure (e.g. room, apartment or house)
qMoved from one HOPWA funded project to HOPWA PH / q Staying or Living with Friends , permanent tenure
qMoved from one HOPWA funded project to HOPWA TH / q Staying or Living with Friends , temporary tenure (e.g. room, apartment or house)
q Owned by client, no on-going housing subsidy / q Substance abuse treatment facility or detox center
q Owned by client, with on-going housing subsidy / q Transitional housing for homeless persons (including homeless youth)
q Permanent housing for formerly homeless persons (such as: CoC project; HUD legacy programs; HOPWA PH) / q Other ______
q Place not meant for habitation (e.g. vehicle, abandoned building, bus/train/subway station/airport, or anywhere outside) / qNo exit interview completed
q Psychiatric hospital or other psychiatric facility / q Client Doesn’t Know
q Rental by client, no ongoing housing subsidy / q Client Refused

Destination Address: City: ______

County State/Province _____ Zip Code

Health Information
Do you have a physical disability? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is there documentation of the disability and its severity on file? / q Yes / q No
If yes, are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
Do you have a developmental disability? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is there documentation of the disability and its severity on file? / q Yes / q No
If yes, are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
Do you have a chronic health condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is there documentation of the disability and its severity on file? / q Yes / q No
If yes, are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
Have you been diagnosed with AIDS or have you tested positive for HIV? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is it expected to substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is there documentation of the disability and its severity on file? / q Yes / q No
If yes, are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
Do you feel that you have a mental health problem? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
If yes, is there documentation of the disability and its severity on file? / q Yes / q No
If you have a mental health problem: Are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t
Know / q Client
Refused
Mental Health: If yes for condition how confirmed? / q Unconfirmed;
presumptive or
self- report / q Confirmed
through
assessment
and clinical
evaluation / q Confirmed by
prior
evaluation or
clinical records
Mental Health: Serious mental illness (SMI) and if SMI how confirmed. / q No / q Unconfirmed;
presumptive
or self- report / q Confirmed by
prior
evaluation or
clinical records / q Client
Doesn’t
Know
qData not
Collected qClient
Refused
Do you have a drug or alcohol problem? / q Alcohol
q Drug
q Both / q No / Know / q Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / q Yes / q No / q Client Doesn’t / q Client
Refused
If yes, is there documentation of the disability and severity on file? / q Yes / q No / Know
If yes, are you currently receiving services or treatment for this condition? / q Yes / q No / q Client Doesn’t / q Client
Refused

INCOME & BENEFITS

Please remember to update the income, benefits & healthcare on the snapshot management tab before finalizing the exit.

Income Source (Choose all that applies)
Note: All PAY INTERVALS should be Monthly / Stated Income / Documentation
q No Financial Resources
q Earned Income (i.e. employment income) / $______
q Unemployment Insurance / $______
q Supplemental Security Income (SSI) / $______
q Social Security Disability Income (SSDI) / $______
q Veteran's Service-Connected Disability Compensation / $______
q Veteran's Non-Service-Connected Disability Compensation / $______
q Private Disability Insurance / $______
q Worker’s Compensation / $______
q Temporary Assistance for Needy Families (TANF) / $______
q General Assistance (GA) / $______
q Retirement Income from Social Security / $______
q Pension from Former Job / $______
q Child Support / $______
q Alimony/Other Spousal Support / $______
q Aid to the Needy and Disabled (AND) / $______
q Old Age Pension (OAP) / $______
q Other Sources / $______
q Client Doesn’t Know
q Client Refused
Non-Cash Benefits (Choose all that applies)
q None q Client Doesn’t Know q Client Refused q Other Benefit Source:______
q Food Stamps/SNAP _$______(amount optional) q TANF Child Care q Temporary Rental Assistance
q TANF Transportation Services q Section 8 or Rental Assistance
q WIC (Women, Infants and Children) q Other TANF-funded Services
Health Insurance
qNo Health Insurance q Client Doesn’t Know q Client Refused q Other______
q MEDICAID q MEDICARE q State Childrens Health Insurance q Veteran’s - VA Medical Services
q Employer provided Health Insurance q COBRA q Private Pay Health Insurance q State Adult Health Insurance
Educational Level (choose one):
q No Schooling Completed / q Nursery to 4th Grade / q 5th or 6th Grade / q 7th or 8th Grade
q 9th Grade / q 10th Grade / q 11th Grade / q 12th Grade, No diploma
q High School Diploma / q GED / q Post-Secondary / q 4 year College
q Graduate School / q Client Doesn’t Know / q Client Refused / q Unknown


Note: This section is for special programs that require additional question sets.

HOPWA QUESTIONS (Only answer these questions for HOPWA programs)
Information Date: _____/_____/______
Receiving Public HIV/AIDS Medical Assistance: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
Receiving AIDS Drug Assistance Program (ADAP): o No o Yes o Client doesn’t know o Client refused
Reason (if no): Applied; decision pending o Applied; client not eligible o Client did not apply
o Insurance type N/A for this client
Information Date: _____/_____/______
T-Cell (CD4) Count Available: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
PATH
Date of Status Determination______/______/______Client Became Enrolled in PATH: qNo qYes
(if no) Reason Not Enrolled: q Client was found ineligible for PATH q Client was not enrolled for other reason(s)
Connection with SOAR: qNo q Yes qClient doesn’t know qClient refused
HUD/VASH QUESTIONS (Only answer these questions for VA programs)
Please describe your general health status: o Excellent o Very Good o Good o Client doesn’t know
o Fair o Poor o Client refused

Client Signature: ______Date: ______

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Colorado HMIS Exit Form