DHS Healthy Transitions Homeless Prevention (HTHP) Outcomes Form
Client Name Date: HMIS ID:
FirstMiddle Last
Data Collection InstructionsA response of “yes” or “no” is required for every single outcome area. “Yes” indicates the client accomplished the outcome. “No” means they are either not focused on that outcome or are making progress but the outcome has not yet been achieved. / HMIS Tips
- Use the General HMIS Instructions and DHS-HTHP Program HMIS User Guide for complete data entry instruction.
- EDA to Entry provider.
- Click on the “Interims” icon next to the HTHP Entry in the Entry/Exit tab
- Select 90-Day Review as the Review Type and enter the date of the review. Update as needed throughout that quarter. Create a new 90-Day Review every quarter.
Section 1: Independent living skills plan
Independent Living Skills Plan completed? Yes No
Number of individual sessions during reporting period? ______#
Number of group sessions youth attended during reporting period? ______#
section 2: transportation
Does youth have Driver's License? Yes No
Does youth have Driver's Permit? Yes No
Successfully navigates public transportation? Yes No
Notes:
Section 3: vital Documents Portfolio
Does youth have their Birth Certificate? Yes No
Does youth have their Social Security Card? Yes No
Does youth have a State ID or Tribal ID Card? Yes No
Section 4: Employment
Is youth currently employed? Yes No
Was youth employed for entire reporting period? Yes No
Section 5: Education
Does youth have GED or High School Diploma? Yes No
If No, are they currently attending school? Yes No
Post-secondary education:
Was youth accepted into a post-secondary education program? Yes No
If Yes, answer the following questions:
Assisted youth in applying for financial aid, including completing the FAFSA? Yes No
Youth obtained Education and Training Voucher (ETV)? Yes No
Section 6: Fiscal
Was the youth provided with financial literacy training in reporting period? Yes No
Section 7: Housing Assistance
Did the youth receive housing assistance this reporting period? Yes No
Amount of assistance provided during quarter? $______
Section 8: Family Reunification and Permanent Connections
Is family reunification a safe, appropriate option for this youth? Yes No
Was youth provided support in connecting and building relationships with family during the reporting period? Yes No
Completed Permanency Pact? Yes No
Completed Youth Connection Scale? Yes No
Was youth provided support in connecting and building a stable relationship with a positive, supporting adult (other than family or agency staff)? Yes No
Section 9: Extended Foster Care
Has the youth attempted to access their extended Foster Care Benefits? Yes No
Section 10: Medical
Does the youth have identified healthcare (including mental health) providers and/or is connected to a clinic? Yes No
If youth is pregnant or parenting, has the youth been offered or referred to support services? Yes No N/A
Section 11: Trauma Screening
Did the agency provide youth with a trauma screening? Yes No
Section 12: SEY/Sex Trafficking
Has the youth exchanged sex acts for money, a place to stay, clothing, food, drugs, transportation, or other things to meet their needs? Yes No
If Yes, was a third-party trafficker involved? Yes No
If Yes, has the youth been offered or referred to Safe Harbor services? Yes No
HTHP Outcomes Form
Last Updated: 05/27/2019Page 1 of 2