Baltimore City Coordinated Entry and Assessment

Baltimore City Coordinated Entry and Assessment

Baltimore Decision Assistance Tool (V.4)

Name of Surveyor:[SW1] / Notes(for use by CAA)
Organization:[SW2]
Location:[SW3]
Date:[SW4]
Prescreen Questions
Questions / Response
1)What brings you here today? (Or “Why are you calling today?”)[SW5]
2)Where did you stay last night?[SW6] / Emergency Shelter**
Safe Haven**
In a car, on the street, or another place not meant for human habitation**
Transitional Housing for homeless persons*
In foster care/group home*
A hospital*
Jail/prison/ Juvenile detention center*
Long-term care facility*
Psychiatric hospital or other facility*
Residential project or halfway house*
In a substance abuse facility/ treatment center*
In own housing (rental)
In own housing (own)
With a friend/family members/other doubled up situation
In a hotel/motel (without voucher)
Other (write in): ______
If staying in a facility, give the name of the facility.
If staying on the street, give the closest landmark or intersection
3)Is that where you stay most of the time? (e.g. 15+ days in a month) / Yes
No
If no to above, where do you usually stay? (write in answer)
4)Is this location in the City or the County? / Baltimore City
Baltimore County
Anne Arundel County
Howard County
Carroll County
Harford County
Other Maryland County
Outside of Maryland
5)Do you know where will you stay tonight?[SW7] / Same place as last night
Emergency Shelter**
Safe Haven**
In a car, on the street, or another place not meant for human habitation**
Transitional Housing for homeless persons*
In foster care/group home*
A hospital*
Jail/prison/ Juvenile detention center *
Long-term care facility*
Psychiatric hospital or other facility*
Residential project or halfway house*
In a substance abuse facility/ treatment center*
In own housing (rental)
In own housing (own)
With a friend/family members/other doubled up situation
In a hotel/motel (without voucher)
Other (write in): ______
Doesn’t know
If staying in a facility, give the name of the facility.
If staying on the street, give the closest landmark or intersection
6)What specifically has caused you to need help with housing assistance? (Indicate all that apply) / Problems with landlord
Has rental or utility arrears
Evicted or in the process of being evicted from a private dwelling
Evicted or in the process of being evicted from housing provided by family or friends
Foreclosure on rental property
Living in housing that has been condemned
Unable to pay rent or contribute monetarily to household
Experiencing high overcrowding
Violence or abuse occurring in the family’s household
Not getting along with family/friends where housing is being shared.
Other: ______
7)Do you feel safe in your current living situation? / If YES, end pre-screen and continue to question 8;
If NO, end pre-screen and proceed to LETHALITY ASSESSMENT (attached).

If person is staying in a place which qualifies them as Category 1 Homeless (See Criteria page) continue on with the assessment.[SW8]

Explain to client:

Based on the answers you provided you might be eligible for certain housing and services available in Baltimore. The reason we need to do this assessment is to see if you might be eligible for any of our programs that serve people who are or have been homeless, based on things like your housing history, health needs, who is in your family, and other things like that. It is completely voluntary to take the assessment, but it is the best way we have to match people to the housing programs we have available. You can refuse to answer any of the questions in the assessment or stop at any time, but answering all of the questions in the assessment will increase your chances of being matched to a program. If you cannot finish this assessment today, you can meet with me at a later date to finish it [Note to Assessor – now is a good time to share your contact information.] Before we start the assessment, I need to go over the consent form and the release of information with you. (Go to BDAT Consent Form and Release of Information form – fill in applicable fields on both forms)

General Information[SW9]
First and Last Name / Nickname
Date of Birth (mm/dd/yyyy):
/ / / Client Contact Phone[SW10]
Unique Client Identifier (UCI)[SW11]
- - - / Client Contact Email
Emergency Contact Name / Emergency Contact Number
Emergency Contact Relationship / Emergency Contact Address
Is there a place you go most days?
If yes, is there a person there who knows you and can help get a message to you? / Are you currently working with an organization or professional helping you with housing or life issues? If yes, what is their name and organization?
Yes
(List name and organization and/or address/location, if known)
No
Name/Organization: ______
Address/Location: ______[SW12]
Citizenship status / Citizen
Legal Permanent Resident
Refugee/Assylee
Undocumented
Doesn’t Know
Refused

(Please scan and email the General Information section to – it cannot be inputted into the PMCP)

Explain to the client:

Now I am going to ask you some questions about where you have lived during the past three years. This helps usmake the best decision about whichhousing programmay be the best fit for you. Remember,this information is voluntary, but the more details you can rememberwill help us make the best choice.

History of Housing and Homelessness
8)Earlier you said that you stayed at (name Category 1 qualifying location stated by client in Q-2); how long have you stayed there? [SW13] / ____ years ___ months ____ days
If client stayed less than 90 days to question above:
9)Where did you stay immediately prior to staying at (location from Q-2)? [SW14]**continue asking client until you’ve covered a period of time going back 3 years from today, or until you’ve recorded enough eligible episodes to determine chronicity. / List below only those locations that are emergency shelters, Safe Havens, or places unfit for human habitation.
a) Location 1: / Location 1 Type:
Shelter
Safe Haven
Place Unfit for Human Habitation
Location 1 Specific Location (Give address, intersection, landmark or housing facility):
Location 1 approximate dates of stay:
From ___mm_____/dd______/yyyy______
To ___mm______/dd______/yyyy______
b) Location 2: / Location 2 Type:
Shelter
Safe Haven
Place Unfit for Human Habitation
Location 2 Specific Location (Give address, intersection, landmark or housing facility):
Location 2 approximate dates of stay:
From _mm_____/dd______/yyyy______
To __mm______/dd______/yyyy______
c) Location 3: / Location 3 Type:
Shelter
Safe Haven
Place Unfit for Human Habitation
Location 3 Specific Location (Give address, intersection, landmark or housing facility):
Location 3 approximate dates of stay:
From _mm_____/dd______/yyyy______
To __mm______/dd______/yyyy______
d) Location 4: / Location 4 Type:
Shelter
Safe Haven
Place Unfit for Human Habitation
Location 4 Specific Location (Give address, intersection, landmark or housing facility):
Location 4 approximate dates of stay:
From _mm_____/dd______/yyyy______
To __mm______/dd______/yyyy______
10)Do you have a disabling condition, that is to say, a physical, mental, or emotional impairment which is not expected to go away (expected to be of long-continued and indefinite duration), substantially impedes your ability to live independently, and (is of such a nature that) such ability could be improved by more suitable housing conditions? / Yes
No
Refused

To client: Now I am going to ask you some questions about who lives with you, or any children who might live with you if you weren’t homeless.

Household Composition:
11)If you were placed in housing, would you be living alone? Or are there other family members who would be in your household?[SW15] / Yes
No
____Single Adult ______Family
Note: If assessing a family, from here forward, ask questions with the designation “you or a member of your family/household” where noted. “Your family,” means your immediate family, e.g. those who would live with you if you had housing.
12)Which of these terms best defines your gender identity? (allow [SW16]multiple boxes to be checked)
Only ask if person does not identify as Transgender above:[SW17]
Were you assigned a gender at birth different from the gender you are living? / Male
Female
Transgender Male (female to male, Trans Man)
Transgender Female (male to female, Trans Woman)
Gender Non-conforming
Gender Queer
Agender
Gender Not Listed
Other ______
Refuse
Yes
No
Refuse
13)How many children under 18 are currently living with you? / # _____Children Under 18
14)Collect names, DOB, genders, relationship, of all other family members who would live with the household if housed. Add additional pages as needed. (Please scan and email the matrix of family members to – only UCI and Relationship to HoH will be inputted into the PMCP)[SW18]
Name: ______
UCI: ______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______/ Name: ______
UCI: ______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______/ Name: ______
UCI______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______
Name: ______
UCI: ______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______/ Name: ______
UCI: ______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______/ Name: ______
UCI: ______
DOB:______
Gender: M /F /Other
Relationship to HOH:
Spouse
Co-head
Other adult ______
Child
Grandchild
Other______
15)Is anyone pregnant in your household? / Yes
No
Refused
16)Are you a veteran or have you ever served in any branch of the Armed Forces or Military?
If, yes:
Which branch of the service were you a part of?
What date did you enter the service?
What was your date of release from service?
What kind of discharge did you have?
Are you registered at a VA Hospital? / Yes
No
Refused
(Check all that apply)
Army
Navy
Air Force
Marine Corps
Coast Guard
Other
Month: ______Year: ______
Month: ______Year: ______
Honorable
General Honorable Conditions
Other than Honorable
Bad Conduct
Don’t know
Refused
Yes
No
Refused

To client: Now I am going to ask you some questions about things that might have happened to you (your family) during the past few months. Some of these questions are very personal andmight be hard to answer. The questions are designed to help us match your family’s needs to programs that most closely meet these needs.

Risks:
17)In the past 3 months, how many times have you (or a family member) been to the emergency department/room? / # times ______
18)In the past 6 months, how many times have you (or a family member) been questioned by police or arrested? / # times ______
19)In the past 6 months, how many times have you (or a family member) been taken by ambulance to the hospital? / # times ______
20)In the past 6 months, how many times have you (or a family member) used a crisis service, including a walk in center or a suicide prevention centers? / # times______
21)In the past year, how many times have you (or a family member) been hospitalized as an inpatient (admitted to the hospital)? / # times______
22)Have you (or a family member) been attacked or beaten up since you’ve become homeless? / Yes
No
Refused
23)Have you (or a family member) threatened or tried to harm yourself or anyone else in the last year? / Yes
No
Refused
24)Do you (or a family member)) have any civil or criminal legal stuff going on right now? / Yes
No
Refused
25)Does anybody force or trick you (or a family member) to do things that you do not want to do? (for example take your money or use your money for things you don’t want / Yes
No
Refused
26)Have you (or a family member) ever done things like exchange sex for money, run drugs for someone, have unprotected sex with someone you don’t know, share a needle, or anything like that? / Yes
No
Refused

To client: Now I am going to ask you some questions about things like your income and relationships with other people. Some of these questions are very personal and might be hard to answer. The questions are designed to help us match your family’s needs to programs that most closely meet these needs.

Socialization and Daily Functions
27)Do you (or family member) owe anybody money, or is there anybody who thinks you (or your family member) owe(s) them money? / Yes
No
Refused
28)Do you (or your family) have any money that comes in on a regular basis, like from a job or government benefit, working under the table, odd jobs, day labor, or anything like that?[SW19]
1)What kind/source? [ask about pending applications for income like SSI/SSDI]
2)About how much comes in monthly from everyone in the household? / Yes
No
Refused
List Sources:______
______
Estimated monthly Income: $______
29)Do you (or your family) have enough money to cover your basic living expenses each month? / Yes
No
Refused
30)Are there people who care about you and could help you if you were connected with services or problem solving assistance (to talk through the issues you indicated)? / Yes
No
Refused
31)Do you (or a family member) maintain any relationships with friends, family, or other people only because you need them to meet your basic needs and not because you like their company? / Yes
No
Refused
32)OBSERVE ONLY (DO NOT ASK):
Do you detect signs for poor hygiene or daily living skills of the head of household or any family member / Yes
No
Unable to Determine

To client: Now I am going to ask you some questions about your health, mental health, and history of substance use. Again, some of these questions are very personal, and while they might be hard to answer, your responses will help us identify the program that best meets your needs.

Health and Wellbeing
Health Care and Physical Health
33)Where do you usually go for healthcare or when you’re not feeling well? / Emergency Room
Specific Hospital (write in)______
VA
Clinic (write in) ______
Health Care for the Homeless
“My Doctor”
“Does not go for healthcare”
Do you have now, have you ever had, or has a healthcare provider told you (or a family member) every been told that you have any of the following medical conditions:
34)Kidney disease/End Stage Renal Disease or Dialysis / Yes, me
Yes, family member (indicate who) ______
No
Refused
35)History of frostbite, Hypothermia, or Immersion Foot / Yes, me
Yes, family member (indicate who)______
No
Refused
36)Liver disease, Cirrhosis, or End Stage Liver Disease / Yes, me
Yes, family member (indicate who) ______
No
Refused
37)HIV+/AIDS / Yes, me
Yes, family member (indicate who) ______
No
Refused
38)Do you have any of the following medical conditions? / History of heat stroke or heat exhaustion
Heart disease, arrhythmia, or irregular heartbeat
Swollen, infected, or ulcers on legs or feet
Diabetes
Asthma
Blindness
Emphysema
Cancer
Hepatitis C
TB
Refused
39)OBSERVE ONLY (DO NOT ASK):
Do you observe signs or symptoms of a serious health condition? / Yes
No
Unable to Determine
Mental Health
40)Have you (or someone in your family) ever been taken to a hospital against your will for mental health reasons? / Yes, me
Yes, family member (indicate who) ______
No
Refused
41)Have you (or a family member) gone to the emergency room because you weren’t feeling 100% well emotionally, or because of your nerves? / Yes, me
Yes, family member (indicate who) ______
No
Refused
42)Have you (or a family member) spoken to a psychiatrist, psychologist, or other mental health professional in the last 6 months because of your mental health – whether that was voluntary or because someone insisted you do so? Or have you wanted to? / Yes, me
Yes, family member (indicate who)
No
Refused
43)Have you (or a family member) ever had a serious brain injury or head trauma? / Yes, me
Yes, family member (indicate who)
No
Refused
44)Have you (or a family member) ever been told you have a developmental disability or lead poisoning? / Yes, me
Yes, family member (indicate who)
No
Refused
45)Do you (or a family member) have any medicines prescribed to you by a doctor that you do not take, for any reason? / Yes, me
Yes, family member (indicate who)
No
Refused
46)Have you (or a family member) ever experienced any emotional, physical, psychological, or other type of abuse or trauma which help was not sought for, and/or which has caused your homelessness? / Yes, me
Yes, family member (indicate who)
No
Refused
47)OBSERVE ONLY (DO NOT ASK):
Do you observe signs or symptoms of severe, persistent mental illness or severely compromised cognitive functioning? / Yes
No
Unable to Determine
Substance Abuse
48)Have you (or someone in your family) ever had problematic drug or alcohol use, abused drugs or alcohol, or been told you do? / Yes, me
Yes, family member (indicate who)
No
Refused
49)Are you (or someone in your family) currently using drugs and/or alcohol on a regular basis? / Yes, me
Yes, family member (indicate who)
No
Refused
50)Have you (or someone in your family) used non-prescription injection drugs in the last 6 months? / Yes, me
Yes, family member (indicate who)
No
Refused
51)Have you (or someone in your family) ever been treated for drug or alcohol problems and returned to drinking or using drugs? / Yes, me
Yes, family member (indicate who)
No
Refused
52)Have you (or someone in your family) used non-beverage alcohol like cough syrup, mouthwash, rubbing alcohol, cooking wine or anything like that in the past 6 months? / Yes, me
Yes, family member (indicate who)
No
Refused
53)Have you (or someone in your family) blacked out because of your alcohol or drug use in the past month? / Yes, me
Yes, family member (indicate who)
No
Refused
54)Families ONLY: Has a family member under 21 consumed alcohol 4 times or more in the last month or used drugs at any point in time during the last month – including marijuana or prescription pills to get high? / Yes, me
Yes, family member (indicate who)
No
Refused
55)OBSERVE ONLY (DO NOT ASK):
Do you observe signs or symptoms of problematic alcohol or drug use? / Yes
No
Unable to Determine
Tri-morbidity:[SW20]You indicated in your responses that there is a medical condition, experience with mental health services and experience with substance use. Is that the same member of the family in all of those instances? / Yes
No
Unable to Determine

To clients in families WITH CHILDREN only: Now I am going to ask you some questions about things like your relationships with other people and your family. Again, some of these questions are very personal, and while they might be hard to answer, they really help us see what needs your family has.[SW21]