Program: Location/Address Exiting From: Keeping Unit: Yes No

/
ST of NH DHHS
DIVISION OF COMMUNITY BASED CARE SERVICES
BUREAU OF HOMELESS AND HOUSING SERVICES
105 PLEASANT ST., CONCORD, NH 03301
603-271-5059 1-800-852-3345, Ext. 5059
Fax: 603-271-5139 TDD Access: 1-800-735-2964 www.dhhs.nh.gov
Nicolas Toumpas, Commissioner
Nancy L. Rollins, Associate Commissioner

NEW HAMPSHIRE HOMELESS MANAGEMENTINFORMATION SYSTEMS

(NH-HMIS)

HPRP CLIENT CONSERT FORM

New Hampshire Homeless Management Information System (NH-HMIS) is used by agencies working together to provide services to individuals and families experiencing homelessness. NH-HMIS is administered and maintained by Harbor Homes, Inc. (HHI).

This system is required by the United States Department o Housing and Urban Development (HUD) and gathers identifying information on persons served in various housing programs to create an unduplicated count and picture o who receives what kind o housing-related services in New Hampshire.

With your permission, we collect and enter personal identifying information into NH-HMIS, or reasons that are discussed in our “Uses and Disclosures Brochure.”

Personal identifying information includes: Name, Social Security Number, Date of Birth, and Zip Code of Last Permanent Residence.

Yes, I authorize this HPRP provide agency to collect and enter personal identifying information about me into NH-HMIS, for the sole purpose of compiling data.

Also, please verify the following:

I have received a copy of and understand the NH-HMIS Client Fact Sheet.

This authorization is valid for eighteen months (18) from the date signed or at termination from the HPRP program, whichever comes first.

Client Name (please print) Client Signature Date

Guardian Name (please print) Guardian Signature Date

Witness Name (Please Print) Witness Signature Date

NEW HAMPSHIRE HOMELESSNESS PREVENTION AND RAPID RE-HOUSING PROGRAM (HPRP)

ENTRY TOOL

CLIENT NAME Entry Date: //

HPRP ENTRY TOOL (6/09/2011) Page 1

Address:

Phone number: () - Email:

SSN: -- SSN Data Quality: Select OneFull SSN ReportedPartial SSNRefusedDon't Know/Don't Have

DOB: // Date of Birth Type: Select OnePartial Date ReportedDont KnowRefusedFull Birth Date Reported

ZIP CODE of last permanent address or City/State Zip Data Quality: Select OneFull or Partial Zip Code ReportedDont KnowRefused

HPRP ENTRY TOOL (6/09/2011) Page 1

Entry Housing Status Select OneLiterally HomelessImminently losing their housingUnstably Housed and at risk of losing housingStably Housed

HPRP ENTRY TOOL (6/09/2011) Page 1

First time homeless? (if client is “unstably housed” or “at risk of losing housing”, the answer to this question is “no”) Select OneYESNO

Race (If client is multiracial, note primary (P) and secondary (S) races.

HPRP ENTRY TOOL (6/09/2011) Page 1

Primary Secondary

Select OneAmerican IndianAlaskan NativeAsianBlackNative HawaiianOtherUnknownWhite Select OneAmerican IndianAlaskan NativeAsianBlackNative HawaiianOtherUnknownWhite

HPRP ENTRY TOOL (6/09/2011) Page 1

Ethnicity Select OneHispanic/LatinoNon-Hispanic/Latino

Gender Select OneFemaleMaleOtherTransgender Male to FemaleTransgendered Female to Male

The response for the next two questions will be for the entire household, unless a name is listed.

1. Disability? Select OneYesNo IF YES, WHO IS NOT DISABLED IN THE FAMILY?

2. US Military Veteran? Select OneYesNo

Household Members

NAME: / Relationship / DoB
SSN / Gender Select OneFemaleMaleDon't KnowRefusedOtherTransgender Male to FemaleTransgendered Female to Male / Race Select OneAmerican IndianAlaskan NativeAsianBlackNative HawaiianOtherUnknownWhite
NAME: / Relationship / DoB
SSN / Gender Select OneFemaleMaleDon't KnowRefusedOtherTransgender Male to FemaleTransgendered Female to Male / Race Select OneAmerican IndianAlaskan NativeAsianBlackNative HawaiianOtherUnknownWhite
NAME: / Relationship / DoB
SSN / Gender Select OneFemaleMaleDon't KnowRefusedOtherTransgender Male to FemaleTransgendered Female to Male / Race Select OneAmerican IndianAlaskan NativeAsianBlackNative HawaiianOtherUnknownWhite

Residence Prior to Program Entry: Select OneEmergency Shelter/Motel paid by voucherTransitional HsgPermanent Hsg for formerly Homeless personsPsychiatric Treatment facilitySubstance abuse treatmentHospitalJail, PrisonDont KnowRefusedRental by client no subsidyOwned by client, No SubsidyWith familyWith FriendsMotel not paid by voucherFoster Care/Group HomePlace not meant for Human HabitationOtherSafe HavenRental by Client with VASH subsidyRental by Client with OTHER subsidyOwned by client, with hsg subsidy

HPRP ENTRY TOOL (6/09/2011) Page 1

HPRP ENTRY TOOL (6/09/2011) Page 1

Length of Stay in Residence Prior to Program Entry: Select OneOne Week or LessMore than one week, less thanone monthOne to Three monthsMore than three months, less than one yearone year or longerDont knowRefused

HPRP ENTRY TOOL (6/09/2011) Page 1

HPRP ENTRY TOOL (6/09/2011) Page 1

Income received from any source in past 30 days?  Select OneYesNoDon't KnowRefused

(Beside each income type, list clients’ name who is receiving the benefit.)

Monthly Income (cash)

Kind of Income / Amount / Member Receiving Income / Kind of Income / Amount / Member Receiving Income
Earned Income $ / General Assistance $
Unemployment Insurance $ / Retirement Income from Social Security $
SSI $ / Veteran’s Pension $
SSDI $ / Child Support $
Veteran Disability Payment $ / Pension from a former Job $
Private Disability Payment $ / Alimony or Other Spousal Support $
Worker’s Compensation $ / Other Source (Specify)
TANF $ / No Financial Resources
APTD $ / Total Monthly Income $

HPRP ENTRY TOOL (6/09/2011) Page 1

HPRP ENTRY TOOL (6/09/2011) Page 1

Non-Cash benefit received from any source in past 30 days? Select OneYesNoDon't KnowRefused

(Beside each non-cash benefit type, list client’s name who is receiving the benefit.)

Monthly Non-Cash Benefits Monthly Income (cash)

Assistance / Amount / Member Receiving Income / Kind of Income / Amount / Member Receiving Income
Supplemental Nutrition Assistance Program (Food Stamps) $ / TANF Child Care Services $
MEDICAID $ / TANF Transportation Services $
MEDICARE $ / Other TANF Funded Services $
SCHIP $ / Section 8, Public Housing, Rental Assistance $
Special Supplemental Nutrition Program (WIC / Temporary Rental Assistance $
Veteran’s Administration (VA) Medical Services / Other Source (Specify) $

HPRP ENTRY TOOL (6/09/2011) Page 1

HPRP ENTRY TOOL (6/09/2011) Page 1

______

AGENCY INTERVIEWER

Release of Information (ROI) All minor household members will be included on ROI. Receive a signed ROI from each adult member of household.

A COMPLETED HPRP CONSENT FORM (ROI) SHOULD BE FAXED ALONG WITH THE HPRP ENTRY TOOL.

Services – All services will be entered through the head of household. Complete SERVICES for single-member household and multiple-member households. SERVICES will be entered for all household members in multiple-member households using this list of SERVICES.

HPRP Housing Relocation and Stabilization Service Provided

Start Date End Date Amount

Case Management / / / / $

Housing Search & Placement / / / / $

Outreach and Engagement / / / / $

Legal Services / / / / $

Credit Repair / / / / $

HPRP Financial Assistance

Start Date End Date

Rental Assistance (on entry) / / / / $

Rental Assistance (future) / / / / $

Rental Arrearage / / / / $

# of units

Unit type

Unit cost

Rental Security Deposit / / / / $

Utility Payment / / / / $

Utility Arrearage / / / / $

# of units

Unit type

Unit cost

Utility Deposit / / / / $

Moving Cost Assistance / / / / $

Motel/Hotel Voucher / / / / $

Circle appropriate response(s) for questions below.

Marital Status: Select OneSingle MarriedDivorcedSeperatedWidowedOther

HPRP ENTRY TOOL (6/09/2011) Page 1

Where are you currently living? Select OneStreetShelterRental UnitOther (explain) If other is selected, Please explain

HPRP ENTRY TOOL (6/09/2011) Page 1

Are you living in Subsidized Housing? Select OneYesNo

Have you applied for Section 8 or other Subsidized Housing? Select OneYesNo

If yes, where and when?

Are you a US Citizen? Select OneYesNo If No, what is your Alien Status?

Emergency Contact Information

Emergency contact: Telephone number:

Housing

What barriers do you face that could prevent you from obtaining and keeping stable housing (please circle all that apply)? Select OneFinancial StrainInadequate employmentLoss of employmentLow level of educationLegal problemsMental health diagnosisHistory of substance abusePoor rental historyOther (explain)

HPRP ENTRY TOOL (6/09/2011) Page 1

Living Situation

Do you own your own home? Select OneYesNo If yes, are you facing foreclosure? Select OneYesNo

Dates
(start with
most recent) / Address / Housing
Type / Rent
Amount / Past Due? / Reason Left?
Evicted?
Rent / Utilities

Name of Current Landlord:

Phone: Fax:

Transportation

Do you have a car? Select OneYesNo Do you have a valid driver’s license? Select OneYesNo

Employment: (Start with most recent):

Employer/Address / Position / Wage
($/hr avg) / Start/End
Dates /

Assets: (List value of all liquid assets as of date of application):

Source of Asset
(i.e., savings, stocks, etc.) / Current Value / Less Withdrawal Penalty / Total Net Value

Expenses:

EXPENSE / AMOUNT / EXPENSE / AMOUNT / EXPENSE / AMOUNT
Rent / Food / Childcare
Telephone / Transportation / Other
Heat / Electricity / Other

Education

Are you currently in school? Select OneYesNo Last Grade Completed?

Do you have a GED? Select OneYesNo

Are you now, or have you been in a job-training program? Select OneYesNo

If Yes, where and what type of program?

Do you have problems with reading or writing?

Personal History

Do you or anyone in your household have any Physical or Mental health concerns? Select OneYesNo

If yes, please describe:

FALSE INFORMATION WILL RESULT IN DISMISSAL FROM THIS PROGRAM.

By signing, the applicant authorizes the HPRP agency to release their personal information to the Bureau of Homeless and Housing Services or others for the purpose of facilitating housing stability. This authorization will terminate 12 months after the participant’s exit from the HPRP program.

Applicant’s Signature: ______

Date: ______

HPRP ENTRY TOOL (6/09/2011) Page 1