Enclosure 21

FY 2013-2014

PATH Program

Eligibility Screening and Needs Assessment

I. CONTACT INFORMATION

*Name: ______*DOB: ______

SS#: ______Referral Source/Site ______

Current Address/Shelter: ______

Available Transportation/Car: ______

Message phone number: ______

Emergency Contact Person: ______Phone: ______

Address: ______

*II. DEMOGRAPHIC INFORMATION

Age: ____Gender: Male Female Unknown/Decline

Race/Ethnicity: Hispanic/Latino African American White

Asian American Indian/Alaska Native

Native Hawaiian or Other Pacific Islander

2 or More Races Unknown/Decline

Veteran Status: Veteran Non-Veteran Unknown

*III. HOUSING INFORMATION

Housed (Not PATH Eligible) Homeless At Risk of Homelessness

Housing Status at First Contact:

Outdoors Short Term Shelter Long Term Shelter

Own or Someone’s Apt/House/Room Hotel, SRO, Boarding House

Halfway House/Residential Treatment Program Other______

Institution (Psychiatric or other hospital, nursing home) Unknown/Decline

Jail/or Correctional Facility

Time Living on Streets upon First Contact:

Less than 2 days 2days-30 days 31days-90 days 91days-1 year

Over 1 year Unknown

Where you slept last night? ______

What keeps you from immediately locating and maintaining stable housing?

______

IV. MENTAL HEALTH/CO-OCCURRING INFORMATION

Have you ever received Mental Health Services: YesNo

If Yes, Where: ______

Mental Health Medications: ______

*Suspected SMI: No SMI (Not PATH Eligible) Schizophrenia

Other Psychotic Disorders Affective Disorder

Personality Disorder Other SMI

Unknown/Undiagnosed SMI

*Substance Abuse:

Co-Occurring Substance Use Disorder SA Only (Not PATH Eligible)

No Co-Occurring Substance Use Disorder Unknown if SA

PATH Eligibility Criteria:

Homeless or imminent risk of becoming homeless; and

Suspected of having a serious mental illness; or Co-Occurring Disorder.

**Eligible and Enrolled in a PATH Service (date) ______

Eligible but Not Enrolled in PATH. Why? ______

Not Eligible and Not Enrolled in PATH

**Continue ONLY if PATH Eligible and Enrolled in PATH Service

V. MEDICAL INFORMATION

Medical/Dental/Vision Issues: Yes No

If Yes, Please Identify: ______

Physical Health Medications: ______

Physical Health Physician/Clinic: ______

VI. EMPLOYMENT INFORMATION

Willing and Able to Work: Yes No

Currently Employed: Yes No

If Able to Work, Why Unemployed?______

Type of Jobs Interested In:______

VII. INCOME INFORMATION

Earned Income…………………………………….$______

Other Assistance…………………………………. $______

CalFresh/Food Stamps.…………………………..$______

Financial Resources: SSI/SSDI VA TANF WIC Amount: $______

Medicare # ______Medi-Cal #______

*VIII. AVAILABLE PATH SERVICES INTERESTED IN:(Check all that apply)

Community Mental Health Services

Screening and Diagnostic Treatment Services

Habilitation and Rehabilitation Services

Alcohol or Drug Treatment Services

Supportive and Supervisory Services in Residential Settings

Referrals for Primary Health Services, Job Training, or Education Services

Housing Services:

Housing Services: 1. Minor Renovation, Expansion and Repair of Housing

Housing Services: 2. Planning of Housing

Housing Services: 3.The costs associated with matching eligible homeless individuals with appropriate housing situations

Housing Services: 4. Technical assistance in applying for housing assistance

Housing Services: 5. Improving the coordination of housing services

Housing Services: 6. Security deposits

Housing Services: 7. One-time rental payments to prevent eviction

IX. ASSESSED RESOURCES AND SERVICE NEEDS: (Check all that apply)

Family Reunification Immediate Housing Mental Health Services

Drug/Alcohol Service Medical Services Employment

Income (SSI/SSDI) Dental Services TANF

ID/Birth CertificateVision/GlassesCalFresh Program/Food Stamps

Legal ServicesOther Needs______

X. ASSESSED READINESS TO CHANGE (check one)

Client Is Not Seriously Considering Change. (Pre-contemplation)

Client Is Seriously Considering Change. (Contemplation)

Client Is Ready to Make a Change. (Preparation)

Client Is Making a Change. (Action)

______

PATH Staff Name: (Print) Date

PATH Staff Name: (Signature):______

FY 2013-2014

Eligibility Screening and Needs Assessment

An intake form that documents eligibility for the program is required for all PATH enrolled individuals. The Eligibility Screening and Needs Assessment form collects all required information for both the intake form and all required information on PATH enrolled individuals for the Quarterly Performance Report and PATH Annual Report. Additional helpful information is included on this form. If the county chooses to use different version of this form, the following information is required:

  1. Contact Information-

Name- to assist with unduplicated counts

Date of Birth (DOB) or Age (at time of enrollment)

  1. Demographic Information
  2. Gender
  3. Race/Ethnicity
  4. Veterans Status
  5. Housing Status at First Contact
  6. Time Living on the Streets at First Contact
  7. Mental Health/Co-Occurring Information
  8. Principal Mental Illness Diagnosis
  9. Co-Occurring Substance Use Disorder
  10. PATH Eligibility Information
  11. Eligible for PATH Services
  12. Literally Homeless or at Imminent Risk of Homelessness; and
  13. Suspected of having a Serious Mental Illness or Co-Occurring Disorder
  14. Enrollment Date
  15. PATH Available Services Interested In
  16. Staff Name, Date, and Signature

PATH 2013-14 Request for Application Page 1 of 4