Coordinated Assessment First-Time Intake - Form for HHS of Two Or More - Version 11/10/2014

Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

Print on White Paper

(!) Indicates OPTIONAL QUESTION

Prior to starting any Intake, your first step is alwaysto sign on to HW HMIS website and use the Generate Intake Feature in the left hand menu. If that fails to produce an Intake Form, use the Standardized HMIS Paper Form instead.

This Paper intake form is an exact match for the "Generated Intake Form for Individuals" except it has an additionalscoring component (VI, below).

All questions are required; this form will be rejected if even one question is left unanswered!

Vulnerability Index (VI) Total Score
Add up the "1s" from all later pages, and enter at right.

If the VI = 10 or greater, client is recommended for a PSH or Housing First Assessment.
If the VI = 6-9, client is recommended for a Rapid Re-housing Assessment.
If the VI = 0-4, client is not recommended for a Housing and Support Assessment.

/ ______ / Jump to Page
CLIENT ID FOR HH MEMBER
ENTRY QUESTIONS
CASH INCOME
NON-CASH BENEFITS
HEALTH/EMOTIONAL CONDITIONS
SERVICE QUESTIONS
PERFORMANCE MEASURES

Submit this form within 14 days of intake to:______

Head of Household: ______SSN: ______- ______- ______DOB___/___/_____

NOTE: If this is a program where the family must be Chronically Homeless to be eligible, make sure that the adult who is Chronically Homeless is listed as the “Adult Head of Household” above.

HW HMIS Username (ex:” cssroad”):______

HW HMIS Project Name (ex: “Road to Success”):______

HW Agency Name (ex: “Catholic Social Services”):______

Your Phone: (type in this format: 508-123-3456):_____-______-______Your Fax: _____-______-______

Your Email Address:______

Name of your HMIS Supervisor at your agency:______

Assessing the Intake for completeness and legibility (assessment is done by Data Entry Staff):

Dear HMIS Supervisor at (list Agency) ______

We entered the data on this applicant. When the applicant exits, please have your staff submit the Exit Info using blue paper (so that we know it’s not another Entry Intake)

Your staff must make the following fixes before we can accept this form. Please make the corrections and re-submit this Intake within 3 days of receipt of this page.

Bed Lists are missing for some dates.

Crisis mode - Forms arrived just prior to reporting deadline. We should have received these forms sooner!

 Form contains unusable answers; see where we’ve marked up the form.

 Forms arrived more than 14 days afterIntake.

Incomplete - the form was not completely filled out, but the missing information is required by HMIS.

Pages were missing or out of order. This doubles our work burden. Put the pages in order and resubmit.

Poor print or fax quality. Please send us a clearer copy so that we can read it easily.

Sloppy handwriting.Please use B L O C K P R I N T (with more white space between letters).

Administrative Info (top half of this page)is missing or incomplete; we must have this to enter client data.

You did not submit anHMIS compliant Intake. Either use the HW version or make yours compliant with that.

Answers on this form conflict with info we already have re: this client. Resolve using the Generate Intake process.

 Other reason: ______

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

FUNDING AGENCYPROGRAMS FUNDED BY THIS AGENCY
Color in the box to indicate the funding agency.Color in the circle to indicate the program type.
 = = 
HUD Housing and Urban Development / CoCPrograms(Continuum of Care programorMcKinney Vento programs)
 SHPProject (Supportive Housing)
 S+CProject (Shelter Plus Care)
 SROProject (Moderate Rehabilitation/Single Room Occupancy)
HUD Housing and Urban Development / ESG Programs (“Emergency Solutions Grants”)
Emergency Shelter Project
Street Outreach Project
Homeless Prevention / Rapid Re-Housing Project
HUD Housing and Urban Development / HOPWA Program (Housing Opportunities for Persons with AIDS)
US Dep’t of Veterans Affairs (VA) /  DCHVDomiciliary Care for Homeless Veterans Project
 GPDGrant and Per Diem Project
 SSVFSupportive Services for Veteran Families Project
 VHPDVeterans Homelessness Prevention Demonstration Project
HUD and VA
HUD and U.S. Dpt. of Veterans Affairs /  VASH Veterans Affairs Supportive Housing Project
HHS, SAMHSA
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration / PATH Programs Projects for Assistance in Transition from Homelessness
HHS, ACF FYSB
U.S. Department of Health and Human Services, Administration for Children and Families’, Family and Youth Services Bureau / RHY Programs(Runaway and Homeless Youth)
Transitional LivingProject
Maternal Group HomeProject
Street OutreachProject
National Runaway Switchboard Project
State– but funding originates from one of the federal reports above. / If funding originatesfrom one of the federal agencies listed above, fill in the circle next to that federal agency, so we know which questions to answer on the HMIS website.
State – but funding originates at the state level and the state report is likely to be unique. / Program Type and Name: ______

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

CLIENT ID FOR HH MEMBER 1(HoH):
NAME, INCLUDING SUFFIX (JR, SR, III, etc.) / Client does not know /

Client refused

I only got a partial name, streetname, or codename

Data not collected – unacceptable answer

Full Legal First Name /  /  /  / 
Full Middle Name / Client definitely does not have a middle name!
Last Name
Suffix? / N/A Sr Jr II III IV V VI VII VIII

MOTHER’S MAIDEN NAME (last name before she was married)

SOCIAL SECURITY NUMBER AGEDATE OF BIRTH (mm/dd/yyyy)

- / - / / / /

SSN ASSESSEDDATE OF BIRTH TYPE Vulnerability Index (VI)

Full SSN / Partial SSN / Full DOB / Partial / Approximate DOB / 1. If ≥60 yrs, enter "1" 
Doesn’t Know/Doesn’t Have / CR / CDNK / CR

US CITIZEN or GREENCARDIDENTITY WAS VERIFIEDHoH SIGNED A RELEASE of INFORMATION

Yes / Client does not know (CDNK) / Yes / Yes
Client Refused (CR) / No / No

(!)STATE-ASSIGNED ID FOR BENEFITS OR HEAD OF HOUSEHOLD’S ALIEN REGISTRATION # (if applicable)

HOUSEHOLD DESIGNATIONSelf (Head of Household-HoH)
VI: HOMELESS CLASSIFICATION / (!) 2. If yes, enter "1" 
Has gone Homeless continuously for at least 12 months? Yes No CDNK CR
Has gone Homeless at least 4 times in the past 3 years? Yes No CDNK CR
HoH HAS HEALTH CONDITIONS LASTING > WEEK? / Yes No CDNK CR
SPECIFY THE DISABILITIES (You will list them again on a later page – i.e. you’ll be asking the client twice):
 Substance Use: Alcohol only Substance use: Drugs only Substance Use: BothAlcohol and Drug
Developmental Disability
HIV/AIDS
Mental Health IssuesPhysical Disability (the Outside Body – blind, deaf, crutch, paraplegic, etc.)
 Other Chronic Health Condition ______
(ex: diabetes, high blood pressure, Hep C, Alzheimer’s, COPD)

BASED ON PREVIOUS TWO ANSWERS, IS HOUSEHOLD CHRONICALLY HOMELESS? i.e. ADULT HASE A DISABILITY AND FAMILY HAS BEEN: 1. HOMELESS 4 TIMES IN THE PAST 3 YEARS OR ELSE 2. CONTINUOUSLY HOMELESSFOR 1 YEAR OR MORE?

Yes No CDNK CR

If you have answered “Yes” to the last two questions, this client/household is CHRONICALLY HOMELESS.

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

GENDER / Male / Female / Other
Transgendered M to F / Transgendered F to M / CDKN / CR

ACTUAL SEXUALORIENTATION(!)PERCEPTION OF "OTHERNESS”

Did Not Ask
 Heterosexual
Questioning / Unsure / Too young to know
Gay Lesbian Bisexual CR / “Due to age, no one thinks about it (Child, Young Teen, Elderly).”
“Everyone knows I’m Heterosexual.”
“Most people haven’t figured out that I’m GLBTQ, Questioning, Intersex, Androgynous, or Asexual.”
“Most people know that I’m GLBTQ or Questioning, Intersex, Androgynous, or Asexual.”
“Some people think I’m Gay or Lesbian but I’m not.”  CR
ETHNICITY * / RACE(s)you may select up to five races if client is multi-racial
Hispanic / Latino / American Indian or Alaskan Native
Non-Hispanic / Non-Latino / Asian / White
CDNK / Black / African American / CDNK
CR / Native/Hawaiian or Other Pac Islander / CR

*Cuban, Mexican, Puerto Rican, South or Central American, Spanish, Other Spanish culture of origin

(!)COUNTRY OF ORIGIN / ANCESTRY: / (!)PRIMARY LANGUAGE:

U.S. MILITARY VETERAN?(!)TYPE OF DISCHARGE:

YesCDNK
NoCR / Did Not AskGeneralMedicalOther
HonorableDishonorableBad conduct

(!)IF YOU ARE NOT A VETERAN, ARE YOU:

THE SPOUSE or PARTNER (PRESENT OR FORMER) OF A VETERAN?THE CHILD OF A VETERAN?

The spouse or partner (present or former) of a veteran? / The child of a veteran?

CASE MANAGEMENT NOTES TAKEN FROM PROGRAM VISITS TO ANY PRIOR PROGRAMS

______

END OF HoH QUESTIONS

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

Household Questions– skip this page if working with an Unaccompanied Adult or Unaccompanied Teen

LIST ALL OTHER MEMBERS OF THE HOUSEHOLD

Name / Relationship to HOH / Date of Birth
mm - dd - yyyy / Social Security Number
1 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
2 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
3 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
4 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
5 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
6 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
7 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
8 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
9 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -
10 /  Add’l Adult ≥ 18  Child ≤ 17 / - - / - -

TOTAL HOUSEHOLD SIZE (number above plus 1 more for Head of Household): ______PERSONS

HOMELESS TIER:

N/A (not HomelessInstitutional DischargeShort Term or Diversion or Relocation to avoid Shelter/Hotel
Chronic ShelteredChronic Unsheltered

IS THIS HOUSEHOLD CHRONICALLY HOMELESS? (SEE LAST ANSWER FROM PREVIOUS PAGE)

Yes
CDNK / No
CR

BEFORE PROCEEDING, IMMEDIATELY FIND AND COMPLETE THE HMIS Intake Pages for Additional HH Members(green paper) 

END OF Household QUESTIONS

Client ID Questions for HH Member 2:
NAME, INCLUDING SUFFIX (JR, SR, III, etc.) / N/A / Client does not know /

Client refused

I only got a partial name, streetname, or codename

Data not collected – unacceptable answer

Full Legal First Name /  /  /  / 
Full Middle Name / clientdefinitely does not have a middle name!
Last Name
Suffix? /  Sr Jr II III IV V VI VII VIII / 

MOTHER’S MAIDEN NAME (last name before she was married) ______

SOCIAL SECURITY NUMBERDATE OF BIRTH (m/d/y)

- / - / / / /

SSN ASSESSEDDATE OF BIRTH TYPE Vulnerability Index (VI)

Full SSN / Partial SSN / Full DOB / Partial / Approximate DOB / 1. If ≥60 yrs, enter "1" 
Doesn’t Know/Doesn’t Have / CR / CDNK / CR

US CITIZEN or GREENCARDIDENTITY WAS VERIFIEDHoH SIGNED A RELEASE of INFORMATION

Yes / Client Doesn’t Know (CDK) / Yes / Yes
Client Refused (CR) / No / No

(!)STATE-ASSIGNED ID FOR BENEFITS OR HEAD OF HOUSEHOLD’S ALIEN REGISTRATION # (if applicable)

HOUSEHOLD DESIGNATION Child of HoH (17 or under) Spouse or Partner Other Adult NOT related to HoH
Other Adult related to HoH (includes any child that is 18 or older)
VI: HOMELESS CLASSIFICATION / 2. If yes, enter "1" 
Has gone Homeless continuously for at least 12 months? Yes No CDNK CR
Has gone Homeless at least 4 times in the past 3 years? Yes No CDNK CR
HoH HAS HEALTH CONDITIONS LASTING > WEEK? / Yes No CDNK CR
SPECIFY THE DISABILITIES (You will list them again on a later page – i.e. you’ll be asking the client twice):
 Substance Use: Alcohol only Substance use: Drugs only Substance Use: BothAlcohol and Drug
Developmental Disability
HIV/AIDS
Mental Health IssuesPhysical Disability (the Outside Body – blind, deaf, crutch, paraplegic, etc.)
 Other Chronic Health Condition ______
(ex: diabetes, high blood pressure, Hep C, Alzheimer’s, COPD)

Yes No CDNK CR

If you have answered “Yes” to the last two questions, this client/household is CHRONICALLY HOMELESS.

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

GENDER of this HH Member

MaleData not collected - unacceptable answer / FemaleOther
Transgendered M to FTransgendered F to MCDNKCR

ACTUAL SEXUALORIENTATION(!)PERCEPTION OF "OTHERNESS”

Did Not Ask
 Heterosexual
Questioning / Unsure / Too young to know
Gay Lesbian Bisexual CR / “Due to age, no one thinks about it (Child, Young Teen, Elderly).”
“Everyone knows I’m Heterosexual.”
“Most people haven’t figured out that I’m GLBTQ, Questioning, Intersex, Androgynous, or Asexual.”
“Most people know that I’m GLBTQ or Questioning, Intersex, Androgynous, or Asexual.”
“Some people think I’m Gay or Lesbian but I’m not.”  CR
ETHNICITY * / RACE(s) you may select up to five races if client is multi-racial
Hispanic / Latino / American Indian or Alaskan Native
Non-Hispanic / Non-Latino / Asian
CDNK / Black, African American, or Caribbean Black / White
CR
Data not collected - unacceptable answer / Native/Hawaiian or Other Pacific Islander / CDNK
Data not collected - unacceptable answer / CR

*”Hispanic” = Cuban, Mexican, Puerto Rican, South or Central American, Spanish, other Spanish culture of origin

(!)COUNTRY OF ORIGIN / ANCESTRY: / (!)PRIMARY LANGUAGE:
(!)OTHER LANGUAGES SPOKEN AT HOME:

U.S. MILITARY VETERAN?(!)TYPE OF DISCHARGE

YesCDNK
NoCR / Did Not AskGeneralMedicalOther
HonorableDishonorableBad conduct

(!)IF YOU ARE NOT A VETERAN, ARE YOU:

THE SPOUSE or PARTNER (PRESENT OR FORMER) OF A VETERAN?THE CHILD OF A VETERAN?

The spouse or partner (present or former) of a veteran? / The child of a veteran?

CASE MANAGEMENT NOTES FOR THIS PARTICULAR CLIENT,TAKEN FROM PROGRAM VISITS TO ANY PRIOR PROGRAMS

______

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

Client ID Questions for HH Member 3:
NAME, INCLUDING SUFFIX (JR, SR, III, etc.) / N/A / Client does not know /

Client refused

I only got a partial name, streetname, or codename

Data not collected – unacceptable answer

Full Legal First Name /  /  /  / 
Full Middle Name / clientdefinitely does not have a middle name!
Last Name
Suffix? /  Sr Jr II III IV V VI VII VIII / 

MOTHER’S MAIDEN NAME (last name before she was married) ______

SOCIAL SECURITY NUMBERDATE OF BIRTH (m/d/y)

- / - / / / /

SSN ASSESSEDDATE OF BIRTH TYPE Vulnerability Index (VI)

Full SSN / Partial SSN / Full DOB / Partial / Approximate DOB / 1. If ≥60 yrs, enter "1" 
Doesn’t Know/Doesn’t Have / CR / CDNK / CR

US CITIZEN or GREENCARDIDENTITY WAS VERIFIEDHoH SIGNED A RELEASE of INFORMATION

Yes / Client Doesn’t Know (CDK) / Yes / Yes
Client Refused (CR) / No / No

(!)STATE-ASSIGNED ID FOR BENEFITS OR HEAD OF HOUSEHOLD’S ALIEN REGISTRATION # (if applicable)

Yes No CDNK CR

If you have answered “Yes” to the last two questions, this client/household is CHRONICALLY HOMELESS.

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

GENDER of this HH Member

MaleData not collected - unacceptable answer / FemaleOther
Transgendered M to FTransgendered F to MCDNKCR

ACTUAL SEXUALORIENTATION(!)PERCEPTION OF "OTHERNESS”

*Cuban, Mexican, Puerto Rican, South or Central American, Spanish, Other Spanish culture of origin

(!)COUNTRY OF ORIGIN / ANCESTRY: / (!)PRIMARY LANGUAGE:

U.S. MILITARY VETERAN?(!)TYPE OF DISCHARGE:

YesCDNK
NoCR / Did Not AskGeneralMedicalOther
HonorableDishonorableBad conduct

(!)IF YOU ARE NOT A VETERAN, ARE YOU:

THE SPOUSE or PARTNER (PRESENT OR FORMER) OF A VETERAN?THE CHILD OF A VETERAN?

The spouse or partner (present or former) of a veteran? / The child of a veteran?

CASE MANAGEMENT NOTES FOR THIS PARTICULAR CLIENT, TAKEN FROM PROGRAM VISITS TO ANY PRIOR PROGRAMS

______

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Coordinated Assessment – First-Time Intake - Form for HHS of Two or More - version 11/10/2014

Client ID Questions for HH Member 4:
NAME, INCLUDING SUFFIX (JR, SR, III, etc.) / N/A / Client does not know /

Client refused

I only got a partial name, streetname, or codename

Data not collected – unacceptable answer

Full Legal First Name /  /  /  / 
Full Middle Name / clientdefinitely does not have a middle name!
Last Name
Suffix? /  Sr Jr II III IV V VI VII VIII / 

MOTHER’S MAIDEN NAME (last name before she was married) ______

SOCIAL SECURITY NUMBERDATE OF BIRTH (m/d/y)

- / - / / / /

SSN ASSESSEDDATE OF BIRTH TYPE Vulnerability Index (VI)

Full SSN / Partial SSN / Full DOB / Partial / Approximate DOB / 1. If ≥60 yrs, enter "1" 
Doesn’t Know/Doesn’t Have / CR / CDNK / CR

US CITIZEN or GREENCARDIDENTITY WAS VERIFIEDHoH SIGNED A RELEASE of INFORMATION

Yes / Client Doesn’t Know (CDK) / Yes / Yes
Client Refused (CR) / No / No

(!)STATE-ASSIGNED ID FOR BENEFITS OR HEAD OF HOUSEHOLD’S ALIEN REGISTRATION # (if applicable)