HMIS Multimember Household Exit Packet (10/01/2016)
(FOR AGENCY USE ONLY)
Case Manager: ______Program Exit Date: ____/_____/______
Number in Household: ______Program Name/Grant:______
This section is to be filled out for the Head of Household
Legal First Name: ______Legal Middle Name: ______
Legal Last Name: ______Suffix: ______
Program Exit
Destination: (choose one):
o Deceased / o Rental by client, with VASH Housing Subsidy
o Emergency shelter, including hotel/motel paid for with emergency shelter voucher / o Rental by client, with GPD TIP subsidy
o Foster care home or foster care group home / o Rental by client, with other ongoing housing subsidy
o Hospital or other residential non-psychiatric medical facility / o Residential project or halfway house with no homeless criteria
o Hotel or motel paid for without an emergency shelter voucher / o Safe Haven
o Jail, prison or other juvenile detention facility / o Staying or Living with Family, permanent tenure
o Long-term care facility or nursing home / o Staying or Living with Family, temporary tenure (e.g. room, apartment or house)
o Moved from one HOPWA funded project to HOPWA PH / o Staying or Living with Friends , permanent tenure
o Moved from one HOPWA funded project to HOPWA TH / o Staying or Living with Friends , temporary tenure (e.g. room, apartment or house)
o Owned by client, no on-going housing subsidy / o Substance abuse treatment facility or detox center
o Owned by client, with on-going housing subsidy / o Transitional housing for homeless persons (including homeless youth)
o Permanent housing for formerly homeless persons (such as: CoC project; HUD legacy programs; HOPWA PH) / o Other ______
o Place not meant for habitation (e.g. vehicle, abandoned building, bus/train/subway station/airport, or anywhere outside) / o No exit interview completed
o Psychiatric hospital or other psychiatric facility / o Client Doesn’t Know
o Rental by client, no ongoing housing subsidy / o Client Refused
Destination Address (optional): ______City: ______
County ______State ______Zip Code
Contact for any questions regarding documents or collection practices.
Health InformationDo you have a physical disability? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Do you have a developmental disability? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Do you have a chronic health condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Have you been diagnosed with AIDS or have you tested positive for HIV? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
HoH Health Information Continued
Do you feel that you have a mental health problem? / o Yes / o No / o Client Doesn’t Know / o Client RefusedIf yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If you have a mental health problem: Are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
How confirmed (for PATH programs ONLY) / o Unconfirmed; presumptive or self-report / o Confirmed
through
assessment and
clinical evaluation / o Confirmed by prior
evaluation or clinical records
Serious mental illness (SMI) and, if SMI, how confirmed? (for PATH programs ONLY) / o No / o Unconfirmed; presumptive or self-report / o Confirmed through
assessment and clinical
evaluation
o Confirmed by prior
evaluation or clinical records / o Client doesn’t know
o Client refused
Do you have a drug or alcohol problem? / o Alcohol
o Drug
o Both / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Note: This section is for special programs that require additional question sets.
Information Date: _____/_____/______
Receiving Public HIV/AIDS Medical Assistance: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
Receiving AIDS Drug Assistance Program (ADAP): o No o Yes o Client doesn’t know o Client refused
Reason (if no): Applied; decision pending o Applied; client not eligible o Client did not apply
o Insurance type N/A for this client
Information Date: _____/_____/______
T-Cell (CD4) Count Available: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
PATH
Date of Status Determination______/______/______Client Became Enrolled in PATH: qNo qYes
(if no) Reason Not Enrolled: q Client was found ineligible for PATH q Client was not enrolled for other reason(s)
Connection with SOAR: qNo q Yes qClient doesn’t know qClient refused
HoH INCOME/ NON-CASH/ HEALTH
o No Financial Resources o Private Disability Insurance$______o Alimony/Other Spousal Support $______
o Earned Income (i.e. employment income) $______o Worker’s Compensation $______o Aid to the Needy and Disabled (AND) $___
o Unemployment Insurance $______o Temporary Assistance for Needy Families (TANF)$______o Old Age Pension (OAP) $______
o Supplemental Security Income (SSI) $______o General Assistance (GA) $______o Other Sources $______
o Social Security Disability Income (SSDI) $______o Retirement Income from Social Security $______o Client Doesn’t Know
o Veteran's Service-Connected Disability Compensation $______o Pension from Former Job $______o Client Refused
o Veteran's Non-Service-Connected Disability Compensation $______o Child Support $______
Do you have documentation of all your sources? o Yes o No
What documentation do you have?______
Non-Cash Benefits (Check all that apply)
o None o Other Benefit Source:______o Food Stamps/SNAP _$______(amount optional)
o TANF Child Care o Temporary Rental Assistance o TANF Transportation Services o Section 8 or Rental Assistance
o WIC (Women, Infants and Children) o Other TANF-funded Services o Client Doesn’t Know o Client Refused
Health Insurance
o No Health Insurance o Other______o MEDICAID o MEDICARE o State Childen’s Health Insurance
o Veteran’s - VA Medical Services o Employer provided Health Insurance o COBRA o Private Pay Health Insurance o State Adult Health Insurance
o Client Doesn’t Know o Client Refused
Person #2 (Adult Not HoH)
Legal First Name: ______Legal Middle Name: ______
Legal Last Name:______Suffix: ______
Program Exit
Person #2 Health Information
Do you have a physical disability? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Do you have a developmental disability? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Do you have a chronic health condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Have you been diagnosed with AIDS or have you tested positive for HIV? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Person #2 Adult/Not HoH Health Information Continued
Do you feel that you have a mental health problem? / o Yes / o No / o Client Doesn’t Know / o Client RefusedIf yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and its severity on file? / o Yes / o No
If you have a mental health problem: Are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
How confirmed (for PATH programs ONLY) / o Unconfirmed; presumptive or self-report / o Confirmed
through
assessment and
clinical evaluation / o Confirmed by prior
evaluation or clinical records
Serious mental illness (SMI) and, if SMI, how confirmed? (for PATH programs ONLY) / o No / o Unconfirmed; presumptive or self-report / o Confirmed through
assessment and clinical
evaluation
o Confirmed by prior
evaluation or clinical records / o Client doesn’t know
o Client refused
Do you have a drug or alcohol problem? / o Alcohol
o Drug
o Both / o No / o Client Doesn’t Know / o Client Refused
If yes, is it expected to be of long-continued and indefinite duration and substantially impair your ability to live independently? / o Yes / o No / o Client Doesn’t Know / o Client Refused
If yes, is there documentation of the disability and severity on file? / o Yes / o No
If yes, are you currently receiving services or treatment for this condition? / o Yes / o No / o Client Doesn’t Know / o Client Refused
Note: This section is for special programs that require additional question sets.
Information Date: _____/_____/______
Receiving Public HIV/AIDS Medical Assistance: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
Receiving AIDS Drug Assistance Program (ADAP): o No o Yes o Client doesn’t know o Client refused
Reason (if no): Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client
Information Date: _____/_____/______
T-Cell (CD4) Count Available: o No o Yes o Client Doesn’t Know o Client Refused
Reason (if no): o Applied; decision pending o Applied; client not eligible o Client did not apply o Insurance type N/A for this client o Client doesn’t know o Client refused
PATH
Date of Status Determination______/______/______Client Became Enrolled in PATH: qNo qYes
(if no) Reason Not Enrolled: q Client was found ineligible for PATH q Client was not enrolled for other reason(s)
Connection with SOAR: qNo q Yes qClient doesn’t know qClient refused
Person #2 (Adult/Not HoH) INCOME/ NON-CASH/ HEALTH