HOPWA Update Assessment Date: ______

First Name: ______Last Name: ______

Client Location (this is the CoC where the client is staying prior to entry): Check only one

VA-500 - Richmond / VA - 513 Western CoC
VA-521 - Balance of State / VA-514 - Fredericksburg

Receiving Income from any source? Yes No Must complete all questions

Income Source / Yes / No / Data not collected / Incomplete
Alimony or Other Spousal Support
Child Support
Earned Income
General Assistance
Other
Pension/retirement from a Former Job
Private Disability Insurance
Retirement Income Social Security
SSDI
SSI
TANF
Unemployment Insurance
VA Non-Service connected disability pension
VA Service connected disability compensation
Workers Compensation

Receiving any Non-cash benefits: Yes No Must complete all questions

Non-Cash source / Yes / No / Data no collected / Incomplete
Other Source
Other TANF-funded service
WIC
SNAP – Food Stamps
TANF child care services
TANF transportation services
Temporary rental assistance
Sec. 8, Public housing or other ongoing rental assistance

Health Insurance: Yes No Must complete all questions

Health Insurance Type / Yes / No / Data not collected / Incomplete
Medicaid
Medicare
Vet. Admin. Medical service
Employer provided Health Insurance
SCHIP
COBRA
Private Pay Health Insurance
State Health Insurance for Adults
Indian Health Insurance
Other

Disability? Yes No Client Doesn’t Know Client Refused Data not collected

Must complete all questions

Disability Type / Yes / No / Client DNK / Client Refused / Data not collected
Alcohol Abuse
Chronic Health Condition
Developmental
Drug Abuse
HIV/AIDS
Mental Health Problem
Physical
Physical/Medical
Both Alcohol & Drug Abuse

Domestic Violence Victim/Survivor? Yes No Client Doesn’t Know Client Refused

Extent of Domestic violence: Check only one

Within past 3 months / 3 to 6 months / Client Doesn’t Know
From 6 to 12 months / More than a year ago / Client Refused

Data not collected

HIV/AIDs sub Assessment:

If yes for HIV/AIDS, does client have a T-Cell count available?

Yes / Client Refused
No / Data not collected / Client Doesn’t Know

If yes for HIV/AIDS…. what is T-Cell count: ______

If yes for HIV/AIDS, and has T-Cell count, how was the information obtained?

Medical report / Client report / Other

If yes for HIV/AIDS, does client have Viral Load information available?

Yes / Client Refused
No / Data not collected / Client Doesn’t Know

If yes for HIV/AIDS…. what is Viral Load? ______

If yes for HIV/AIDS, and has Viral Load, how was the information obtained?

Medical report / Client report / Other

Receiving Public HIV/AIDs Medical assistance: Check only one

Yes / Client Refused
No / Data not collected / Client Doesn’t Know

If not Receiving Public HIV/AIDs Medical assistance, reason: Check only one

Applied; decision pending / Client did not apply / Client Refused
Applied; client not eligible / Insurance type N/A for client / Client Doesn’t Know

Receiving AIDS Drug assistance program (ADAP): Check only one

Yes / Client Refused
No / Data not collected / Client Doesn’t Know

If not Receiving AIDS Drug assistance program (ADAP), reason: Check only one

Applied; decision pending / Client did not apply / Client Refused
Applied; client not eligible / Insurance type N/A for client / Client Doesn’t Know

Revised 9/27/2016 1