HMISRHYBCP/TLP Intake Form(01-30-2017)

Please answer all questions. Fill out one form for each child member at program entry.

Legal First Name: ______Legal Middle Name: ______

Legal Last Name: Suffix: ______

Name Data quality:Full name reported Partial, street name, or code name reported Client Doesn’t KnowClient Refused

Date of Birth (mm/dd/yyyy): // Full Approximate or Partial ClientDoesn’t Know Client Refused

Social Security #: ______– _____ – ______Full Approximate or Partial Client Doesn’t Know/Don’t Have Client Refused

Tell Us about Your Last Permanent Address (where you last lived for 90 days or more)

CityCounty State/Province

Phone: PH Type: Phone Alt: PH Type:

Email: Contact Preference:

Are You Homeless? (Housing Status): Category 1- Homeless

Category 2- Imminently losing housing

 Category 3- Homeless under other Federal statutes

 Category 4- Fleeing domestic

At risk of losing housing

Stably housed

ClientDoesn’t Know

Client Refused

Disabling Condition:Yes No  ClientDoesn’t Know  Client Refused

Relationship to HoH:Self Child  Spouse Head of household’s other relation member Other (non-relation member)

Veteran Status: (Served/Serving in US Military): Yes  No  ClientDoesn’t Know  Client Refused

Gender: MaleFemale Transgender Male to FemaleTransgender Female to Male Doesn’t identify as male, female, or transgender Client Doesn’t Know Client Refused

Ethnicity: Non-Hispanic/Non-Latino Hispanic/Latino ClientDoesn’t Know  Client Refused

Race (choose all that apply):American Indian or Alaska NativeAsianBlack or African American

Native Hawaiian or Other Pacific IslanderWhiteClient doesn’t know Client Refused

Alias First Name: ______AliasLast Name: ______(optional)

]Income & Benefits

(To be completed by Transitional Living Program Only)

Income Source (Choose all that applies)
Note: All PAY INTERVALS should be Monthly / Stated Income / Documentation
 No Financial Resources
 Earned Income (i.e. employment income) / $______
 Unemployment Insurance / $______
 Supplemental Security Income (SSI) / $______
 Social Security Disability Income (SSDI) / $______
 Veteran's Service-Connected Disability Compensation / $______
 Veteran's Non-Service-Connected Disability Compensation / $______
 Private Disability Insurance / $______
 Worker’s Compensation / $______
 Temporary Assistance for Needy Families (TANF) / $______
 General Assistance (GA) / $______
 Retirement Income from Social Security / $______
 Pension from Former Job / $______
 Child Support / $______
 Alimony/Other Spousal Support / $______
 Aid to the Needy and Disabled (AND) / $______
 Old Age Pension (OAP) / $______
 Other Sources / $______
 ClientDoesn’t Know
 Client Refused
Non-Cash Benefits (Choose all that applies)
 None  ClientDoesn’t Know  Client Refused  Other BenefitSource:______
 Food Stamps/SNAP _$______(amount optional)  TANF Child Care  Temporary Rental Assistance
 TANF Transportation Services  Section 8 or Rental Assistance
 WIC(Women, Infants and Children)  Other TANF-funded Services
HEALTH INSURANCE
No Health Insurance Other______MEDICAID MEDICARE
State Children’s Health InsuranceVeteran’s - VA Medical
Employer provided Health InsuranceCOBRA Private Pay Health Insurance
State Adult Health InsuranceIndian Health Services Program
Client RefusedClient Doesn’t Know

Family Contact Tab: What is the Client’s Current Address? (Click “Is Mailing Address” if you are recording the current address in this tab),

Address:______City:______

County:______State:______Zip:______

Phone: ______PH Type:

Email: ______Contact Preference:______

For persons entering HMIS Project Type: Street Outreach, Emergency Shelter, and Safe Haven
Where did you stay last night– choose one (i.e. Safe haven, Hospital, Hotel, etc.)
Type of Residence: Literally Homeless Situations
Place Not Meant for Habitation (Car or Other Vehicle, Abandoned Building, Bus/Train/Subway Station/ Airport, Street or Camping)
Emergency Shelter, including hotel/motel paid for with emergency shelter voucher
Safe Haven
Interim Housing
Type of Residence: Institutional Situation
Foster care home or foster care group home /  Psychiatric Hospital or other Psychiatric Facility
 Hospital or other residential non-Psychiatric facility /  Long-term Care Facility or nursing home
 Jail, Prison or Other Juvenile Facility / Substance Abuse Treatment Facility or Detox Center
Type of Residence: Transitional and Permanent Housing Situation
 Hotel or Motel Paid for without an Emergency Shelter Voucher / Residential project of halfway house with no homeless criteria
Owned by Client, No Housing Subsidy /  Staying or Living in a Family Member’s Room, Apartment or House
Owned by Client, With Housing Subsidy / Staying or Living in a Friend’s Room, Apartment, or House
Permanent Housing for Formerly Homeless Persons / Transitional Housing for Homeless Persons (including homeless youth)
 Rental by Client, with no ongoing housing subsidy /  Client Doesn’t Know
Rental by Client with VASH Housing Subsidy / Client Refused
 Rental by Client, with GPD TIP subsidy
Rental by Client, with other ongoing housing subsidy
Length of Stay in Prior Living Situation? (choose one):
One night or less One month or more, but less than 90 daysClient Doesn’t Know
Two to six nights 90 days or more but less than one yearClient Refused
One week or more, but less than one month One year or longer
Approximate Date that Homelessness Started? ______
Number of times the client has been homeless on the streets, in ES or Safe haven in the past three years (INCLUDING today- choose one):
0 1 2 3 4 or More Client Doesn’t KnowClient Refused
Total number of months homeless on the streets, in ES or Safe haven in the past three years? (INCLUDING THIS TIME –choose one and please write specific number):
0-12 ______12+ ______Client Doesn’t Know Client Refused
For persons entering HMIS Project Type: Transitional Housing, Permanent Housing, Rapid Re-Housing, Service Only, Day Shelter, Homelessness Prevention, and Coordinated Assessment
Where did you stay last night– choose one (i.e. Safe haven, Hospital, Hotel, etc.)
Type of Residence:Literally Homeless Situations
Place Not Meant for Habitation (Car or Other Vehicle, Abandoned Building, Bus/Train/Subway Station/ Airport, Street or Camping)
Emergency Shelter, including hotel/motel paid for with emergency shelter voucher
Safe Haven
Interim Housing
Length of Stay in Prior Living Situation? (choose one):
One night or less One month or more, but less than 90 daysClient Doesn’t Know
Two to six nights 90 days or more, but less than one yearClient Refused
One week or more, but less than one month One year or longer
Approximate Date that Homelessness Started?______
Number of times the client has been homeless on the streets, in ES or Safe haven in the past three years (INCLUDING today- choose one):
0 1 2 3 4 or More Client Doesn’t KnowClient Refused
Total number of months homeless on the streets, in ES or Safe haven in the past three years? (INCLUDING THIS TIME –choose one and please write specific number):
0-12 ______12+ ______Client Doesn’t Know Client Refused
Type of Residence:Institutional Situation
Foster care home or foster care group home /  Psychiatric Hospital or other Psychiatric Facility
 Hospital or other residential non-Psychiatric facility /  Long-term Care Facility or nursing home
 Jail, Prison or Other Juvenile Facility / Substance Abuse Treatment Facility or Detox Center
Did you stay less than 90 days? Yes No
Length of Stay in Prior Living SituationOne night or lessTwo 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
Note: If “Yes” is answered for “Did you stay less than 90 days?” then answer the questions below.
On the night before you entered the institution, did you stay on the streets, in an emergency shelter or a safe haven?
Yes No
Note: If “Yes” is answered for “On the night before your institution stay…?” then answer the questions below.
Approximate Date that Homelessness Started?______
Number of times the client has been homeless on the streets, in ES or Safe haven in the past three years (INCLUDING today- choose one):
0 1 2 3 4 or More Client Doesn’t KnowClient Refused
Total number of months homeless on the streets, in ES or Safe haven in the past three years? (INCLUDING THIS TIME –choose one and please write specific number):
0-12 ______12+ ______Client Doesn’t Know Client Refused
Type of Residence: Housing Situation
 Hotel or Motel Paid for without an Emergency Shelter Voucher / Residential project of halfway house with no homeless criteria
Owned by Client, No Housing Subsidy /  Staying or Living in a Family Member’s Room, Apartment or House
Owned by Client, With Housing Subsidy / Staying or Living in a Friend’s Room, Apartment, or House
Permanent Housing for Formerly Homeless Persons / Transitional Housing for Homeless Persons (including homeless youth)
 Rental by Client, with no ongoing housing subsidy /  Client Doesn’t Know
Rental by Client with VASH Housing Subsidy / Client Refused
 Rental by Client, with GPD TIP subsidy
Rental by Client, with other ongoing housing subsidy
Did you stay less than 7 nights? Yes No
On the night before you stayed in this housing situation, did you stay on the streets, in an emergency shelter or in a safe haven?
Yes No
Note: If “Yes” is answered for “On the night before you stayed in this housing situation…?” then answer the questions below.
Length of Stay in Prior Living SituationOne night or lessTwo 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
Note: If “Yes” was answered for “Did you stay less than 7 nights” then answer the questions below.
Approximate Date that HomelessnessStarted?______
Number of times the client has been homeless on the streets, in ES or Safe haven in the past three years (INCLUDING today- choose one):
0 1 2 3 4 or More Client Doesn’t KnowClient Refused
Total number of months homeless on the streets, in ES or Safe haven in the past three years? (INCLUDING THIS TIME –choose one and please write specific number):
0-12 ______12+ ______Client Doesn’t Know Client Refused

Reasons or Contributing Factors to Homeless Situation(choose all that apply):

 Abuse or violence in my home /  Medical expenses
 Alcohol/substance abuse problems /  Mental illness
 Asked to leave /  Moved to find work
 Bad credit /  Problems with public benefits
 Couldn’t pay utilities /  Reasons related to my sexual orientation
 Discharge from foster care /  Relationship problems or family break-up
 Discharged from jail /  Unable to pay rent/mortgage
 Discharged from prison /  Other ______
 Family member or personal illness /  Doesn’t apply to me
 Legal problems / Lost Job Couldn’t find work
Health Information
Do you have a physical disability? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is there documentation of the disability and its severity on file? /  Yes /  No
If yes, are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
Do you have a developmental disability? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is there documentation of the disability and its severity on file? /  Yes /  No
If yes, are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
Do you have a chronic health condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is there documentation of the disability and its severity on file? /  Yes /  No
If yes, are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
Have you been diagnosed with AIDS or have you tested positive for HIV? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is it expected to substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is there documentation of the disability and its severity on file? /  Yes /  No
If yes, are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
Do you have a mental health problem? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
If yes, is there documentation of the disability and its severity on file? /  Yes /  No
If you have a mental health problem: Are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t
Know /  Client
Refused
Do you have a drug or alcohol problem? /  Alcohol
 Drug
 Both /  No / Know /  Client
Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? /  Yes /  No /  Client Doesn’t /  Client
Refused
If yes, is there documentation of the disability and severity on file? /  Yes /  No / Know
If yes, are you currently receiving services or treatment for this condition? /  Yes /  No /  Client Doesn’t /  Client
Refused
DOMESTIC ABUSE
Are you a survivor of domestic or intimate partner violence:  Yes  No  Client Doesn’t Know  Client Refused
If you experienced domestic or intimate partner violence, how long ago did you have this experience?:
 Within the past 3 months /  3 to 6 months ago (excluding 6 months exactly) /  6 to 12 months ago (excluding 12 months exactly)
 One year ago or more /  Client Doesn’t Know /  Client Refused

Sexual Orientation: Heterosexual Gay Lesbian Bisexual Questioning/Unsure Client doesn’t know Client refused

SCHOOL
What is the last grade of school completed?
Less than Grade 5 Grades 5-6 Grades 7-8 Grades 9-11
Grade 12 School Program does not have grade levels GED
Some college  Associates degree  Bachelor’s degree  Graduate degree
 Vocational certification Client doesn’t know Client refused
Please describe your current school situation:
Attending school regularlyAttending school irregularlyGraduated from high schoolObtained GED
Dropped outSuspendedExpelledClient doesn’t knowClient refused
EMPLOYMENT
Are you currently employed?  Yes No  Client Doesn’t Know Client Refused
If yes, describe the type of employment: Full-timePart-timeSeasonal or Sporadic (including day-labor)
If no, please tell us why are you unemployed?Looking for workUnable to work Not looking for work
HEALTH
Please describe your general health status: / Excellent / Very Good / Good / Client doesn’t know
Fair / Poor / Client refused
Please describe your dental health status: / Excellent / Very Good / Good / Client doesn’t know
Fair / Poor / Client refused
Please describe your mental health status: / Excellent / Very Good / Good / Client doesn’t know
Fair / Poor / Client refused

Pregnancy (Are you pregnant?): Yes  No  Client Doesn’t Know  Client Refused; If yes, due date: ____/_____/_____ (mo./day/year)

Are you formerly a ward of Child Welfare of a Foster Care Agency?  Yes No  Client Doesn’t Know Client Refused

If yes, for how many years? Less than 1 year 1-2 years3-5+ years

If yes, but for under one year, how many months?

Are you formerly a ward of the Juvenile Justice system?  Yes  No  Client Doesn’t Know Client Refused

If yes, for how many years? Less than 1 year 1-2 years3-5+ years

If yes, but for under one year, how many months?

Young Person’s Critical Issues (Are any of the following a critical issue that you face?)
Housing Dynamics / Yes / No
Sexual Orientation/Gender (youth) / Yes / No
Sexual Orientation/Gender (family member) / Yes / No
Housing issues (youth) / Yes / No
Housing issues (family member) / Yes / No
School or educational issues (youth / Yes / No
School or educational issues (family member) / Yes / No
Unemployment (youth) / Yes / No
Unemployment (family member) / Yes / No
Mental Health (youth) / Yes / No
Mental Health (family member) / Yes / No
Health (youth) / Yes / No
Health (family member) / Yes / No
Physical Disability (youth) / Yes / No
Physical Disability (family member) / Yes / No
Mental Disability (youth) / Yes / No
Mental Disability (family member) / Yes / No
Abuse and neglect (youth) / Yes / No
Abuse and neglect (family member) / Yes / No
Alcohol or other drug abuse (youth) / Yes / No
Alcohol or other drug abuse (family member) / Yes / No
Insufficient Income to Support Youth (family member) / Yes / No
Active Military Parent (family member) / Yes / No
Incarcerated parent of youth / Yes / No
If, Incarcerated Parent of youth is yes, please specify:  One parent/legal guardian is incarcerated  Both parents/legal guardians are incarcerated  The only parent/legal guardian is incarcerated
REFERRAL SOURCE
Self-referralIndividual: Parent/GuardianIndividual: Relative of Friend
Individual: Other Adult or Youth Individual: Partner/SpouseIndividual: Foster Parent
Outreach Project: FYSBOutreach Project: OtherTemporary Shelter: FYSB Basic Center Project
Temporary Shelter: Other Youth Only Emergency Shelter Temporary Shelter: Emergency Shelter for Families
Temporary Shelter: Emergency Shelter for Individuals Temporary Shelter: Domestic Violence Shelter
Temporary Shelter: Safe PlaceTemporary Shelter: Other Residential Project: FYSB Transitional Living Project
Residential Project: Other Transitional Living Project Residential Project: Group Home
Residential Project: Independent Living ProjectResidential Project: Job Corps
Residential Project: Drug Treatment CenterResidential Project: Treatment Center
Residential Project: Educational Institute Residential Project: Other Agency Project
Residential Project: Other ProjectHotline: National Runaway Switchboard
Hotline: OtherOther Agency: Child Welfare/CPS
Other Agency: Non-residential Independent Living ProjectOther Project Operated by your Agency
Other Youth Services AgencyJuvenile Justice
Law Enforcement/PoliceReligious Organization Mental HospitalSchool
Other Organization  Client Doesn’t Know Client Refused
If Outreach Project: FYSB Referral source selected how many times were you approached by outreach prior to entering the project? ______times (number)

Have you ever received anything in exchange for having sexual relations with another person, such as money, food, drugs, or shelter?