Community Services Management Information System (CS-MIS) 10/2017 Pg. 1

First Name / MI / Last Name
Assessment Date
Client Location / ☐NE-500 BOS (Anywhere in Nebraska outside of Lincoln/Omaha)
☐NE-502 Lincoln
Income Information
Income from any source? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Total Monthly CASH income: Write in total $ amount and complete the table below Total Monthly Income: $______
Receives Income Sources / Yes / Monthly Amount $ / No
AABD (Aid to Aged, Blind & Disabled) / ☐ / $ / ☐
Alimony or Other Spousal Support / ☐ / $ / ☐
Child Support / ☐ / $ / ☐
Contributions from other People / ☐ / $ / ☐
Earned Income (from job) / ☐ / $ / ☐
General Assistance / ☐ / $ / ☐
Pension or retirement income from job / ☐ / $ / ☐
Pension/Retirement / ☐ / $ / ☐
Private Disability Insurance / ☐ / $ / ☐
Retirement Income from Social Security / ☐ / $ / ☐
Self Employment Wages / ☐ / $ / ☐
SSA / ☐ / $ / ☐
SSDI / ☐ / $ / ☐
SSI / ☐ / $ / ☐
Stipend / ☐ / $ / ☐
Unemployment Insurance / ☐ / $ / ☐
VA Non-service connected disability compensation / ☐ / $ / ☐
VA service-connected disability compensation / ☐ / $ / ☐
Worker’s Compensation / ☐ / $ / ☐
Other (specify): / ☐ / $ / ☐
Non-Cash Benefits Information
Non-cash benefits from any source / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Receives the following Non-cash Benefit Types: / Yes / Monthly Amount $ (if known) / No
Supplemental Nutrition Assistance Program (SNAP)(Food Stamps) / ☐ / $ / ☐
Special Supplemental Nutrition for Women, infants, children(WIC) / ☐ / N/A / ☐
TANF Child Care Services / ☐ / $ / ☐
TANF Transportation services / ☐ / N/A / ☐
Other TANF funded services / ☐ / N/A / ☐
Other (specify): / ☐ / $ / ☐
Health Insurance Information
Covered by Health Insurance / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Type
(Select all that apply) / Covered
Yes / Covered
No
Medicaid / ☐ / ☐
Medicare / ☐ / ☐
State Children’s Health Insurance Program / ☐ / ☐
Veteran’s Administration (VA) Medical Services / ☐ / ☐
Employer-Provided Health Insurance / ☐ / ☐
Health Insurance obtained through COBRA / ☐ / ☐
Private Pay Health Insurance / ☐ / ☐
State Health Insurance for Adults / ☐ / ☐
Indian Health Services Program / ☐ / ☐
Other, Specify: / ☐ / ☐
Outreach
Date of Engagement
Date of PATH Status Determination
Client Became Enrolled in PATH / ☐ Yes ☐ No
If No, reason not enrolled / ☐ Client was found ineligible for PATH ☐ Client was not enrolled for other reason
Connection with SOAR / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused

UNL-Center on Children, Families, and the Law (CCFL)

Community Services Management Information System (CS-MIS) 10/2017 pg. 1