HOPWA Client Intake v.2(6/25-15)

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Client ID: ______

Update Date: ______

CoC Area Client Served: KY-501

Name: ______

FirstMiddleLast

SSN: ______-______-______Date of Birth: ____-_____-______

Veteran Status:

□Yes

□No

□Client Doesn’t Know

□Client refused to answer

______

  1. Zip Code of Last Permanent Address: ______

______

  1. Relationship to the Head of Household:

HOPWA Client Intake v.2(6/25-15)

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□Self – Head of Household

□Head of Household’s child

□Head of Household’s spouse or partner

□Head of Household’s other relation member (other relation to Head of Household other than listed)

□Other – no relation to Head of Household

HOPWA Client Intake v.2(6/25-15)

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______

  1. Race:

HOPWA Client Intake v.2(6/25-15)

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□White

□Black or African-American

□American Indian/Alaska Native

□Asian

□Native Hawaiian or Other Pacific Islander

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. Ethnicity:

HOPWA Client Intake v.2(6/25-15)

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□Non-Hispanic/Non-Latino

□Hispanic/Latino

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. Gender:

HOPWA Client Intake v.2(6/25-15)

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□Female

□Male

□Transgender Male to Female

□Transgender Female to Male

□Other ______

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. Where did you stay last night? - Type of Living Situation:

HOPWA Client Intake v.2(6/25-15)

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□Emergency shelter, including hotel or motel paid for with emergency shelter voucher

□Foster care home or foster care group home

□Hospital or other residential non-psychiatric medical facility

□Hotel or motel paid for without emergency shelter voucher

□Jail, prison, or juvenile detention facility

□Long-term care facility or nursing home

□Owned by client, no ongoing housing subsidy

□Owned by client, with ongoing housing subsidy

□Permanent housing for formerly homeless persons (such as: a CoC project; HUD legacy programs; or HOPWA PH)

□Place not meant for habitation (e.g. a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

□Psychiatric hospital or other psychiatric facility

□Rental by client, no ongoing housing subsidy

□Rental by client, with VASH subsidy

□Rental by client, with GPD TIP subsidy

□Rental by client, with 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 or living in friend’s room, apartment or house

□Substance abuse treatment facility or detox center

□Transitional housing for homeless persons (including homeless youth)

□Other ______

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. How long did you stay there? - Length of Stay in Previous Place

HOPWA Client Intake v.2(6/25-15)

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□One day or less

□Two days to one week

□More than one week, but less than one month

□One to three months

□More than three months, but less than one year

□One year or longer

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. How many times have you slept in a place not meant for human habitation or stayed in an emergency shelter in the last three (3) years?

HOPWA Client Intake v.2(6/25-15)

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□0

□1

□2

□3

□4 or more

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. Have you ever lived in a place not meant for human habitation or an emergency shelter for 365 days straight (continuously)?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client refused to answer

HOPWA Client Intake v.2(6/25-15)

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______

  1. Are you a domestic violence victim/survivor?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. If yes, when did the last experience occur?

HOPWA Client Intake v.2(6/25-15)

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□Within the past three months

□Three to six months ago

□Six months to one year ago

□One year ago or more

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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______

  1. Do you have any income on the day of this application?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

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12a. If yes, please mark source and amount per month:

HOPWA Client Intake v.2(6/25-15)

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□Earned income (employment only) $______

□Unemployment Insurance $______

□Supplemental Security Income (SSI) $______

□Social Security Disability Income (SSDI)$______

□VA Service-Connected Disability Compensation $______

□VA Non-Service-Connected Disability Pension $______

□Private Disability Insurance $______

□Worker’s Compensation $______

□Temporary Assistance for Needy Families (TANF) $______

□General Assistance (GA) $______

□Retirement from Social Security$______

□Pension or Retirement Income from Another Job $______

□Child Support $______

□Alimony and other spousal support $______

□Other source: ______$______

______

  1. Do you have any non-cash benefits on the day of this application?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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13a. If yes, please mark source and amount per month, if applicable:$______

□Supplemental Nutrition Assistance Program (SNAP) – Food Stamps$______

□Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)$______

□TANF Child Care Services$______

□TANF transportation services$______

□Other TANF-funded services$______

□Section 8, public housing, or other ongoing rental assistance$______

□Temporary rental assistance$______

□Other source ______$______

______

  1. Are you covered with any type of health insurance on the day of this application?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

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14a. If yes, please select the type of health insurance:

□Employer-Provided Health Insurance

□Medicaid

□Medicare

□State Children’s Health Insurance Program

□Veterans Administration (VA) Medical Services

□Health Insurance obtained through COBRA

□Private Pay Health Insurance

□State Health Insurance for Adults

14b. If no, please indicate the current stage of enrollment:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

Client Refused

______

  1. Are you receiving public HIV/AIDS Medical Assistance?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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**** If no, please list the reason:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

□Client Refused

______

  1. Are you receiving AIDS Drug Assistance Program (ADAP)?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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**** If no, please list the reason:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

□Client Refused

______

  1. Do you have a Disability?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Intake v.2(6/25-15)

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**If yes, please select type of disability and complete extra questions:

17a. Physical Disability

-Is this Physical Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this disability?

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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17b. Developmental Disability (must have developed prior to age 22)

-Is this Developmental Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this disability?

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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17c. Chronic Health Condition

-Is this Chronic Health Condition expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this disability?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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17d. HIV/AIDS

-Does HIV/AIDS substantially impair your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this disability?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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17e. Mental Health Problem

-Is this Mental Health Problem expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this disability?

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-How was this Mental Health Problem confirmed?

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical records

-If this is considered a Serious Mental Illness (SMI), how was that confirmed?

□Not Considered SMI

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical records

17f. Substance Abuse

□Alcohol Abuse

□Drug Abuse

□Both Alcohol and Drug Abuse

-Is this Substance Abuse Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-Are you currently receiving services or treatment for this condition?

HOPWA Client Intake v.2(6/25-15)

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□Yes

□No

HOPWA Client Intake v.2(6/25-15)

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-How was this Substance Abuse Disability confirmed?

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical record