CT HMIS DOH AIDS & HOPWA Intake

CT HMIS DOH AIDS & HOPWA Intake

Revised 03/20/2017

Instructions: The System Entry Intake is completed if a household cannot be diverted from homelessness and needs to access services in the homeless system. The interviewer should have access to the information captured during the Diversion Screening (if it was conducted) as well as shelter stay history from HMIS (if there is a shelter history). The Intake assesses basic needs and captures HMIS required data elements for program entries. The interviewer should just confirm and update it as needed.

Project Entry Date: ______

Applicant (Head of Household) Information:

First Name: ______Last Name: ______

Middle Name: ______Suffix: ______

Name Data Quality: ¨ Full Name Reported ¨ Partial, Street Name, or Code Name reported ¨ Client Doesn't Know ¨ Client Refused

Date of Birth: __/___/_____ ¨ Approximate or Partial DOB Reported ¨ Client Doesn't Know ¨ Client Refused

Social Security Number: ______-______-______¨ Approximate or Partial SSN Reported ¨ Client Doesn't Know ¨ Client Refused ¨ Data Not Collected

Gender:  Male  Female  Transgender Male to Female  Transgender Female to Male  Other  Client Doesn’t Know  Client Refused ¨ Data Not Collected

If Other, please specify: ______

Primary Language:  English  Spanish  French  Portuguese  Other  Client Doesn’t Know ¨ Data Not Collected

If Other, please specify: ______

Relationship to HOH:  Self  Spouse  Child  Grandparent  Guardian  Other  Client Doesn’t Know ¨ Data Not Collected

If Other, please specify:______

Race:  White  Black or African American  Asian  American Indian or Alaska Native  Native Hawaiian/ Pacific Islander  Client Doesn’t Know

 Client Refused ¨ Data Not Collected

Ethnicity:  Hispanic/Latino  Non-Hispanic/Non-Latino  Client Doesn’t Know  Client Refused ¨ Data Not Collected

Veteran Status: Have you ever been on active duty in the U.S. Military? ¨ Yes ¨ No ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected

Cell Phone: ______Work Phone: ______Email: ______

Emergency Contact Name and Phone #: ______

Additional Household Member Demographics:

Last Name / First Name / Date of Birth / See codes below / Social Security Number / Relationship to Head of Household
* / Veteran
(Y/N) / Disabling Condition
(Y/N)
Middle Name / Suffix / Gender
* / Ethnicity
* / Race
*
*Ethnicity Codes: NH-Non Hispanic/Non-Latino H- Hispanic DK- Client Doesn’t Know CR-Refused
*Race: W- White; B- Black or African American; A- Asian; AI/AN- American Indian and Alaska Native; NH/PI- Native Hawaiian/ Pacific Islander; DK- Client Doesn’t Know; CR- Client Refused
*Gender: M - Male; F - Female; TMF - Transgender Male to Female; TFM - Transgender Female to Male; O - Other; DK - Client Doesn’t Know; CR - Client Refused
*Head of Household’s: C - Child; SP - Spouse or Partner; ORM - Other Relation Member; ONR - Other Non-Relation Member

If “YES” to Veteran Status:

DD214 Order Date (optional) ____/ ____/ ____ DD214 Receive Date (optional) ____/ ____/ ____

Service Connected Disability? ¨ Yes ¨ No ¨ Don't Know ¨ Refused

Branch of military: ¨ Air Force ¨ Army ¨ Marines ¨ Navy ¨ Coast Guard ¨ Client Doesn’t Know ¨ Client Refused ¨ Other
Date entered Service ____/ ____/ ____
Reserves? (optional) ¨ Yes ¨ No
What was your discharge status: ¨ Honorable ¨ General under Honorable Conditions ¨ Under Other than Honorable Conditions ¨ Bad Conduct ¨ Dishonorable

¨ Uncharacterized ¨ Client Doesn’t Know ¨ Client Refused

Years of Service: ______to ______Months of Active Duty: ______

Served in a war zone: ¨ Yes ¨ No ¨ Don't Know ¨ Refused

Theatre of Operations: ¨ World War II ¨ Korean War ¨ Vietnam War ¨ Persian Gulf War (Operation Desert Storm) ¨ Afghanistan (Operation Enduring Freedom)

¨ Iraq (Operation Iraqi Freedom) ¨ Iraq (Operation New Dawn) ¨ Other Peace-keeping Operations or Military Interventions

Client Served Location: ______

Disabling Condition: ¨ Yes ¨ No ¨ Client Doesn't Know ¨ Client Refused

Living Situation:

Type of Residence: (Do not read responses. Ask question and then choose one.)

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 3

¨ Emergency Shelter or hotel / motel paid with ES voucher

¨ Foster care or foster care group Home

¨ Hospital or other residential non-psychiatric medical facility

¨ Hotel / Motel paid without ES voucher

¨ Interim Housing

¨ Jail,prison, or juvenile detention facility

¨ Long-term care facility or Nursing Home

¨ Owned by client, no housing subsidy

¨Owned by client, with ongoing housing subsidy

¨Permanent housing for formerly homeless persons (CoC Project, HUD Legacy Program, HOPWA PH)

¨ Place not meant for human habitation

¨ Psychiatric Hospitalor other psychiatric facility

¨ Rental by client, no ongoing housing subsidy

¨ Rental by client, with VASH subsidy

¨ Rental by client, with GPD TID subsidy

¨ Rental by client, other ongoing housing subsidy

¨ Residential project or halfway house with no homeless criteria

¨ Safe Haven

¨ Staying or living in a family member’s room, apartment or house

¨ Staying orliving in a friend’s room, apartment or house

¨Substance Abuse treatment facility or detox center

¨ Transitional housing for homeless persons

¨Client doesn't know

¨ Client refused

¨ Other

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 3

If Other, please explain: ______

Length of Stay in the Prior Living Situation?

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

¨ One night or less

¨ Two days 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

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

Approximate Date Homelessness Started ____/____/____
Regardless of where they stayed last night-- Number of Times the Client Has Been Homeless on the Streets, in ES, or SH in the Past Three Years Including Today:

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

 Never in 3 Years

 One Time

 Two Times

 Three Times

 Four or More Times

 Client doesn’t know

 Client refused

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

Total Number of Months Homeless on the Streets, in ES, or SH in the Past Three Years:

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

 One Month (this time is the first time)

 2-12 Months (Specify # of Months: ______)

 More than 12 months

 Client Doesn’t Know

 Client Refused

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

Zip Code of Last Permanent Address: ______¨ Partial ¨ Don't Know ¨ Refused

Domestic Violence Survivor? (Head of Household and All Adults): ¨ Yes ¨ No ¨ Don't Know ¨ Refused

If “YES:” When experience occurred?

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

¨ Within the past three months

¨ Three to six months ago (excluding six months exactly)

¨ Six months to one year ago (excluding one year exactly)

¨ One year ago or more

¨ Client doesn’t know

¨ Client refused

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 4

If “YES:” Are you currently fleeing? ¨ Yes ¨ No ¨ Don't Know ¨ Refused
Non-cash benefit from any source? (All Clients) ¨ Yes ¨ No ¨ Client doesn’t know ¨ Client refused ¨ Data Not Collected
Non-cash benefits 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 / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
YES / NO / YES / NO / YES / NO / YES / NO / YES / NO
(SNAP) Food Stamps
Special Supplemental Nutrition Program for WIC
TANF Child Care Services
TANF Transportation
Other TANF Funded Services
Section 8, Public Housing or Rental Assistance
Temporary Rental Assistance
Client Doesn't know
Client Refused
Other (Please Specify):

Health Insurance: ¨ Yes ¨ No ¨ Client Doesn't Know ¨ Client Refused

Pregnancy Status: ¨ Yes ¨ No ¨ Client Doesn't Know ¨ Client Refused ¨ Data Not Collected

If “Yes:” Due Date? ____/____/____

Disabling Conditions (All Clients):

CT Statewide DOH AIDS & HOPWA Intake Assessment (v3.20.2017)Page 9

Head of Household / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
Physical Disability (All Clients)
Yes, No, Client Doesn’t Know, Client Refused
If yes, Documentation of the disability and severity on file? Yes, No
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
If yes, Currently receiving services/treatment for this disability? Yes, No, Client Doesn’t Know, Client Refused
Developmental Disability (All Clients)
Yes, No, Client Doesn’t Know, Client Refused
If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused
If yes, Documentation of the disability and severity on file? Yes, No
If yes, Currently receiving services/treatment for this disability? Yes, No, Client Doesn’t Know, Client Refused
Chronic Health Condition (All Clients)
Yes, No, Client Doesn’t Know, Client Refused
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, DK, Refused
If yes, Documentation of the disability and severity on file? Yes, No
If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused
HIV/AIDS (All Clients)
Yes, No, Client Doesn’t Know, Client Refused
If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused
If yes, Documentation of the disability and severity on file? Yes, No
If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused
Mental Health Problem (All Clients)
Yes, No, Client Doesn’t Know, Client Refused
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
If yes, Documentation of the disability and severity on file? Yes, No
If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused
Substance Abuse (All Clients)
No, Alcohol Abuse, Drug Abuse, Both Alcohol and Drug, Client Doesn’t Know, Client Refused
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
If yes, Documentation of the disability and severity on file? Yes, No
If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused

Income received from any source? (HoH and Adults Only) ¨ Yes ¨ No ¨ Client doesn’t know ¨ Client refused
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 / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
Income Type / Monthly Amount / Monthly Amount / Monthly Amount / Monthly Amount / 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:
Health Insurance (All clients): / Head of Household / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
YES / NO / YES / NO / YES / NO / YES / NO / YES / NO
Covered by Health Insurance? (Yes, No, Client Doesn’t Know, Client Refused)
Medicaid
If NO, Reason: (See choices below)
Medicare
If NO, Reason: (See choices below)
State Children’s Health Insurance Program (CHIP)
If NO, Reason: (See choices below)
Veterans Administration (VA)
If NO, Reason: (See choices below)
Employer-Provided Health Insurance
If NO, Reason: (See choices below)
Health Insurance Obtained through COBRA
If NO, Reason: (See choices below)
Private Pay Health Insurance
If NO, Reason: (See choices below)
*REASON: AD: Applied; decision pending, AC: Applied; client not eligible, CN: Client did not apply, IT: Insurance type N/A for this client, DK: Client Doesn’t Know, R: Client Refused

Medical Assistance (All Household Members with HIV/AIDS):

Head of Household / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
Receiving Public HIV/AIDS Medical Assistance
Yes, No, Client Doesn’t Know, Client Refused
If NO, Reason:
AD: Applied; decision pending, AC: Applied; client not eligible, CN: Client did not apply
IT: Insurance type N/A for this client, DK: Client Doesn’t Know, R: Client Refused
Receiving AIDS Drug Assistance Program (ADAP)
Yes, No, Client Doesn’t Know, Client Refused
If NO, Reason:
AD: Applied; decision pending, AC: Applied; client not eligible, CN: Client did not apply
IT: Insurance type N/A for this client, DK: Client Doesn’t Know, R: Client Refused

Services Provided (Head of Household and All Adults):

Head of Household / HH Member 1 / HH Member 2 / HH Member 3 / HH Member 4
Yes/Date of Service / Yes/Date of Service / Yes/Date of Service / Yes/Date of Service / Yes/Date of Service
Adult Day Care and Personal Assistance
Case Management
Child Care
Criminal Justice/Legal Services
Education
Employment and Training Services
Food/Meals/Nutritional Services
Health/Medical Care
Life Skills Training
Mental Health Care/Counseling
Outreach and/or Engagement
Substance Abuse Services/Treatment
Transportation
Other HOPWA Funded Service

Financial Assistance: HOPWA - STRMU and PHP only (Head of Household)

Short-Term Rent, Mortgage, Utility Assistance (STRMU):

Financial Assistance Type / Financial Assistance Amount
Rental Assistance
Utility Payments
Mortgage Assistance

Permanent Housing Placement (PHP)