CT HMIS PATH (Outreach) Intake
Revised 9/21/2016
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
Gender: Male Female Transgender Male to Female Transgender Female to Male Transgender Does not identify as male, female or transgender unknown Client Doesn’t Know Client Refused
Primary Language Spoken:
¨ English ¨ Spanish ¨ Chinese ¨ Russian ¨ Arabic ¨ Portuguese ¨ Bengali ¨ French ¨ Malay, Indonesian ¨ German
¨ Japanese ¨ Farsi (Persian) ¨ Urdu ¨ Punjabi ¨ Vietnamese ¨ Tamil ¨ Javanese ¨ Korean ¨ Turkish ¨ Telugu ¨ Marathi ¨ Italian ¨ Thai ¨ Burmese
¨ Kannada ¨ Gujarati ¨ Polish ¨ Hindi ¨ Cantonese ¨ Haitian Creole ¨ Unknown ¨ Other: ______
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Ethnicity: Hispanic/Latino Non-Hispanic/Non-Latino Client Doesn’t Know Client Refused
Race: White Black or African American Asian American Indian or Alaska Native Native Hawaiian/ Pacific Islander Client Doesn’t Know Client Refused
Citizenship Status: : ¨ Don’t Know ¨ Eligible Non-Citizen ¨ Non-Citizen ¨ U.S Citizen ¨ Undocumented
Veteran Status: Have you ever been on active duty in the U.S. Military? ¨ Yes ¨ No ¨ Client doesn’t know ¨ Client refused
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.)
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¨ 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
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If Other, please explain: ______
Length of Stay in the Prior Living Situation?
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¨ 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
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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:
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Never in 3 Years
One Time
Two Times
Three Times
Four or More Times
Client doesn’t know
Client refused
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Total Number of Months Homeless on the Streets, in ES, or SH in the Past Three Years:
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One Month ( this time is the first time)
2-12 Months (Specify # of Months: ______)
More than 12 months
Client Doesn’t Know
Client Refused
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¨ Client refused
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Domestic Violence Survivor? (Head of Household and All Adults): ¨ Yes ¨ No ¨ Don't Know ¨ Refused
If “YES:” When experience occurred?
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¨ 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
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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
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.
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? ____/____/____
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Disabling Conditions (All Clients)
Disabling Condition (All Adults)
Yes, No, Client Doesn’t Know, Client Refused / N/A
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
If yes, How confirmed? Confirmed by Prior Evaluation or Clinical Records, Confirmed Through Assessment and Clinical Evaluation, Unconfirmed; Presumptive or Self-report
If yes, Serious mental illness (SMI) and, if SMI, how confirmed? Yes, No, Client Doesn’t Know, Client Refused, Confirmed by Prior Evaluation or Clinical Records, Confirmed Through Assessment and Clinical Evaluation, Unconfirmed; Presumptive or Self Report
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
How Confirmed? Confirmed by Prior Evaluation or Clinical Records, Confirmed Through Assessment and Clinical Evaluation, Unconfirmed; Presumptive or Self-Report
Type of Insurance / YES / NO / IF NO (*Note: This is NOT Required except for HOPWA Programs)
Medicaid / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Medicare / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
State Children’s Health Insurance Program
(CHIP) / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Veterans Administration (VA) Medical Services / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Employer-Provided Health Insurance / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Health Insurance Obtained through COBRA / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
State Health Insurance for Adults / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Private Pay Health Insurance / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Indian Health Services Program / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ client doesn’t know ¨ client refused
Other (Specify) / ¨ applied; decision pending ¨ applied; client not eligible ¨ did not apply ¨ insurance type N/A
¨ 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.
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:
Date of 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(s)
Connection with SOAR: ¨ Yes ¨ No ¨ Client Doesn't Know ¨ Client Refused