Check data quality option: ☐Full Name ☐Partial, street or code name ☐Client doesn’t know ☐Client refused
Maiden Name (if applicable) / Alias or any other names used
Social Security Number(SSN)
Check data quality option: ☐Full SSN ☐Approx. or partial SSN ☐Client doesn’t know ☐Client refused
U.S. Military Veteran / ☐Yes ☐No ☐Client doesn’t Know ☐Client Refused
Date Client Entered Project / Project Name
Date of Birth (DOB) / ☐Full DOB ☐Approx. or partial DOB ☐Client doesn’t know ☐Client refused
Race
(select up to 2) / ☐American Indian or Alaska Native
☐Asian
☐Black or African American / ☐ Native Hawaiian/Pacific Islander
☐White / ☐Client doesn’t know
☐Client Refused
Ethnicity / ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐Client doesn’t know ☐Client refused
Gender
(select one) / ☐Female
☐Male
☐Trans Male / ☐Trans Female
☐Gender Non-Conforming / ☐Client doesn’t know
☐ Client refused
Have a disability of long duration? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Relationship to Head of Household / ☐Self (head of household)
☐ Head of Household’s Child
☐ Head of Household’s spouse or partner
☐ Head of Household’s other relation member / ☐ Other: Non-relation member
☐ Client doesn’t know
☐ Client refused
Client Location / ☐NE-500 BOS (Anywhere in Nebraska outside of Lincoln/Omaha)
☐NE-502 Lincoln
Living Situation: Residence the night before program admission, and length of stay at that residence (complete only 1 section A, B, or C)
A.
Literally Homeless / ☐ Place not meant for habitation
☐ Emergency Shelter, or hotel/motel paid for with emergency shelter voucher
Shelter name:______
☐ Safe Haven
☐ Interim Housing(a housing situation where a chronically homeless person a unit reserved)
Length of stay in: ______days ApproximateDate Started:______
Number of times on the streets, in Emergency Shelter in the past three years including today: ______
Total number of months homeless on the street, in Emergency Shelter in the past three years:______
B.
Institutional Situation / ☐ Foster care home or foster care group home
☐ Hospital or other residential non-psychiatric medical facility
☐ Jail, prison or juvenile detention facility
☐ Long-term care facility or nursing home
☐ Psychiatric hospital or other psychiatric facility
☐ Substance abuse treatment facility or detox center
Length of stay: ______days More than 90 days: ☐ Yes ☐ No
On the night before, did you stay on the streets, in Emergency Shelter, or a Safe Haven? ☐ Yes ☐ No
Approximate Date Started:______
C.
Transitional & Permanent Housing Situation / ☐ Hotel or motel paid for without emergency shelter voucher
☐ Owned by client, no ongoing housing subsidy
☐ Owned by client, with ongoing housing subsidy
☐ Permanent housing (Other than RRH) for formerly homeless persons
☐ 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 (including RRH)
☐ Residential project or halfway house with no homeless criteria
☐ Staying or living in a family member's room, apartment or house
☐ Staying or living in a friend's room, apartment or house
☐ Transitional housing for homeless persons (including homeless youth)
Length of stay: ______days More than 7 days: ☐ Yes ☐ No
On the night before, did you stay on the streets, in Emergency Shelter, or a Safe Haven? ☐ Yes ☐ No
Approximate Date Started:______
Length of Time Homeless Status Documented? / ☐ Yes ☐ No
Income Information
Total Monthly Income: / Income from any source? / ☐ Yes ☐ No
Total Monthly CASH income: Write in total $ amount and complete the table below
Receives Income Sources / Yes / Monthly Amount $ / No
AABD (Aid to Aged, Blind & Disabled) / ☐ / $ / ☐
Alimony or Other Spousal Support / ☐ / $ / ☐ /
Child Support / ☐ / $ / ☐ /
Contributions from other People / ☐ / $ / ☐ /
Earned Income (from job) / ☐ / $ / ☐ /
General Assistance / ☐ / $ / ☐ /
Pension or retirement income from job / ☐ / $ / ☐ /
Pension/Retirement / ☐ / $ / ☐ /
Private Disability Insurance / ☐ / $ / ☐ /
Retirement Income from Social Security / ☐ / $ / ☐ /
Self Employment Wages / ☐ / $ / ☐ /
SSA / ☐ / $ / ☐ /
SSDI / ☐ / $ / ☐ /
SSI / ☐ / $ / ☐ /
Stipend / ☐ / $ / ☐ /
Unemployment Insurance / ☐ / $ / ☐ /
VA Non-service connected disability compensation / ☐ / $ / ☐ /
VA service-connected disability compensation / ☐ / $ / ☐ /
Worker’s Compensation / ☐ / $ / ☐ /
Other (specify): / ☐ / $ / ☐ /
Non-Cash Benefits Information
Non-cash benefits from any source / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Receives the following Non-cash Benefit Types: / Yes / Monthly Amount $ (if known) / No
Supplemental Nutrition Assistance Program (SNAP)(Food Stamps) / ☐ / $ / ☐
Special Supplemental Nutrition for Women, infants, children(WIC) / ☐ / N/A / ☐ /
TANF Child Care Services / ☐ / $ / ☐ /
TANF Transportation services / ☐ / N/A / ☐ /
Other TANF funded services / ☐ / N/A / ☐ /
Other (specify): / ☐ / $ / ☐ /
Health Insurance Information
Covered by Health Insurance / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
Type(Select all that apply) / Covered Yes / Covered No
Medicaid / ☐ / ☐ /
Medicare / ☐ / ☐ /
State Children’s Health Insurance Program / ☐ / ☐ /
Veteran’s Administration (VA) Medical Services / ☐ / ☐ /
Employer-Provided Health Insurance / ☐ / ☐ /
Health Insurance obtained through COBRA / ☐ / ☐ /
Private Pay Health Insurance / ☐ / ☐ /
State Health Insurance for Adults / ☐ / ☐ /
Indian Health Services Program / ☐ / ☐ /
Other ( Specify): / ☐ / ☐ /
Select below for each disability type
Disability Type / Has Disability / If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently / Above condition going to be long term?
Yes / No / Yes / No / Yes / No
Alcohol Abuse / / / / / /
Drug Abuse / / / / / /
Both alcohol and drug abuse / / / / / /
Chronic Health Condition / / / / / /
Developmental Disability / / / / / /
HIV/AIDs / / / / / /
Mental Health Problem / / / / / /
Physical Disability / / / / / /
OUTREACH
Date of initial Contact
Date of Engagement
Referral Source / ☐Self-Referral
☐Individual: Parent/Guardian/Relative/Friend/Foster Parent/Other Individual
☐Outreach Project
☐Temporary Shelter
☐Residential Project
☐Hotline
☐Child Welfare/CPS
☐Juvenile Justice
☐Law Enforcement/Police
☐Mental Hospital
☐School
☐Other Organization
If Outreach Project, Number of times approached by outreach prior to entering project
Date of BCP Status Determination / Youth Eligible for RHY Services / ☐ Yes ☐ No
If no for “youth eligible for RHY services” Reason why services are not funded by BCP Grant / ☐Out of age range
☐Ward of the State-Immediate Reunification
☐Ward of the Criminal Justice System-Immediate Reunification
☐Other
If Yes for “Youth Eligible for RHY Services”, Runaway youth? / ☐ Yes ☐ No
Sexual Orientation / ☐ Heterosexual
☐ Gay
☐ Lesbian / ☐ Bisexual
☐Questioning/Unsure / ☐Client doesn’t know
☐Client refused
Last Grade Completed / ☐Less than Grade 5
☐Grades 5-6
☐Grades 7-8
☐Grades 9-11
☐Grade 12/High School Diploma / ☐School Program does not have grade levels
☐GED
☐Some College
☐Associate’s Degree / ☐Bachelor’s Degree
☐Graduate Degree
☐Vocational Certification
☐Client doesn’t know
☐Client refused
School Status / ☐Attending School Regularly
☐Attending School Irregularly
☐Graduated High School / ☐Obtained GED
☐Dropped Out
☐Suspended / ☐Expelled
☐Client doesn’t know
☐Client refused
Employed? / ☐ Yes ☐ No ☐Client doesn’t know ☐Client refused
If Yes, Type of Employment / ☐ Full-Time ☐ Part-Time ☐Seasonal/Sporadic (including day labor)
If No, Why not Employed / ☐ Looking for work ☐ Unable to work ☐Not looking for work
General Health Status / ☐ Excellent
☐ Very good / ☐ Good
☐ Fair / ☐ Poor
☐ Client refused
Dental Health Status / ☐ Excellent
☐ Very good / ☐ Good
☐ Fair / ☐ Poor
☐ Client refused
Mental Health Status / ☐ Excellent
☐ Very good / ☐ Good
☐ Fair / ☐ Poor
☐ Client refused
Pregnant? / ☐Yes ☐No ☐Client doesn’t know ☐Client refused
If Yes, Projected Birth Date / _____/______/______
Formerly a Ward of Child Welfare/Foster Care Agency / ☐Yes ☐No ☐Client doesn’t know ☐Client refused
Number of Years / ☐Less than one year☐1 to 2 years ☐3 to 5 or more years
If Less than one year, Number of Months / ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 ☐11
Formerly a Ward of Juvenile Justice System / ☐Yes ☐No ☐Client doesn’t know ☐Client refused
Number of Years / ☐Less than one year☐1 to 2 years ☐3 to 5 or more years
If Less than one year, Number of Months / ☐1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 ☐11
Family Critical Issues
Unemployment-Family Member / ☐Yes ☐No / Mental Health Issues-Family member / ☐Yes ☐No
Physical Disability-Family Member / ☐Yes ☐No / Alcohol or Substance Abuse-Family Member / ☐Yes ☐No
Insufficient Income to support youth-Family member / ☐Yes ☐No / Incarcerated Parent of Youth / ☐Yes ☐No
Service Transactions
Service Type(write-in) / Start Date / End Date
Referrals
Need(Service Referring for) / Referral Date
Client’s Residence/Last Permanent Address
Street Address
City / State / Zip code
County of Current Residence / County of Legal Residence
Preferred Method of Contact
Phone Number
1 UNL-Center on Children, Families, and the Law (CCFL) & Community Services Management Information System (CS-MIS) 10/17
I ______understand information about me and/or my dependents listed below is entered into a database system called ServicePoint. This system helps to better understand homelessness, to improve service delivery and to evaluate the effectiveness of services provided. Participation in data collection is a critical component of our community’s ability to provide the most effective services and housing possible. The information that is collected is protected by limiting access to the database and limiting what information may be shared. Access to the data and sharing of the data is in compliance with the standards set by the federal, state and local regulations governing confidentially of client records. Every person and agency that is authorized to read or enter information into the system has signed an agreement to maintain the security and confidentiality of the information.
By signing this form, I authorize the following:
The information collected by this agency will be included in ServicePoint and only partner agencies, which have entered into an HMIS Agency Participation Agreement, may be used to:
- Produce a client profile at intake that will be shared with collaborating agencies
- Produce aggregate level reports regarding use of services
- Track individual program-level outcomes
- Identify unfilled service needs and plan for enhancements
- Allocate resources among agencies engaged in services
By signing this form, I authorize the following:
I authorize the partner agencies and their representatives to share basic information regarding my family members listed below and/or me. I understand that this information is for the purpose of assessing my/our needs for housing, utility assistance, food, counseling and/or other services.
The information may consist of the following PPI (Personal Protected Information):
- Name
- Homeless History
- Disabling Condition
- Date of Birth
- Family Composition
- Photo (if applicable)
- Social Security Number
- Income/Non-cash
- Housing information
- Gender
- Veteran Status
- Health Insurance Status
- Ethnicity and Race
- Domestic Violence
- Client Location
- Residence Prior to Project Entry
- VI-SPDAT
I Understand That:
The partner agencies have signed agreements to treat my information in a professional and confidential manner. I have the right to view the client confidentiality polices used by the HMIS partner agencies
Staff members of the partner agencies who will see my information have signed agreements to maintain confidentiality regarding my information.
The release of my information does not guarantee that I will receive assistance; my refusal to authorize the use of my information does not disqualify me from receiving assistance.
My records are protected by federal, state, and local regulations governing confidentially of client records and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
This authorization will remain in effect until I revoke it in writing, and I may revoke authorization at any time, if I revoke my authorization, all information about me already in the database will remain.
This release if valid for ______years from the date of my signature below.
I understand I may withdraw my consent at any time.
Partner Agencies: A list of the partner agencies within the Nebraska Homeless Management Information System may be viewed prior to signing this form.
List all Dependent Children under 18 in the household, if any (first, last and DOB)
Auditors or funders who have legal rights to review the work of this agency, including the U.S. Department of Housing and Urban Development and Nebraska Department of Health and Human Services Homeless Assistance Program may see my complete file in HMIS if services received are funded by their Department/s.
Please initial one of the following levels of consent:
___ I give authorization for me and my dependents listed above, Protected Personal and relevant Information to be entered into the NMIS and shared between Partner Agencies.
Or
___I do not consent to the inclusion of personal information in the NMIS about me and any dependents listed above.
______
Consumer’s SignatureDate
______
Agency Staff Name(print) Agency Staff Signature Date
10/2016