HOPWA Client Exit V.2 (6-25-15)

HOPWA Client Exit v.2 (6-25-15)

Client ID: ______

Exit Date: ______

CoC Area Client Served: KY-501

Of the following, which best describes your housing situation (location) upon exit of this program?

□Deceased

□Emergency Shelter, including hotel or motel paid for with an emergency shelter voucher

□Foster care home or foster care group home

□Hospital or other residential non-psychiatric medical facility

□Hotel or motel paid for without an emergency shelter voucher

□Jail, prison, or juvenile detention facility

□Long-term care facility or nursing home

□Moved from one HOPWA funded project to HOPWA PH

□Moved from one HOPWA funded project to HOPWA TH

□Owned by client, no ongoing housing subsidy

□Owned by client, with ongoing housing subsidy

□Permanent housing for formerly homeless persons (such as a CoC project; HUD legacy programs; or HOPWA PH)

□Place not meant for habituation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

□Psychiatric hospital or other psychiatric facility

□Rental by client, no ongoing housing subsidy

□Rental by client, with Veterans Assistance Supportive Housing (VASH) subsidy

□Rental by client, with Grant Per Diem (GPD) TIP subsidy

□Rental by client, with other ongoing housing subsidy

□Residential project or halfway house with no homeless criteria

□Safe Haven

□Staying or living with family, permanent tenure

□Staying or living with family, temporary tenure

□Staying or living with friends, permanent tenure

□Staying or living with friends, temporary tenure

□Substance abuse treatment facility or detox center

□Transitional housing for homeless persons

□Other ______

□No Exit Interview completed

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

Have you had any changes in your income since entering this project?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

2a. If yes, please mark source and amount per month:

HOPWA Client Exit v.2 (6-25-15)

□Earned income (employment only) $______

□Unemployment Insurance $______

□Supplemental Security Income (SSI) $______

□Social Security Disability Income (SSDI)$______

□VA Service-Connected Disability Compensation $______

□VA Non-Service-Connected Disability Pension $______

□Private Disability Insurance $______

□Worker’s Compensation $______

□Temporary Assistance for Needy Families (TANF)$______

□General Assistance (GA) $______

□Retirement from Social Security$______

□Pension or Retirement Income from Another Job $______

□Child Support $______

□Alimony and other spousal support $______

□Other source: ______$______

______

Have you had any changes in your non-cash benefits since entering this project?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

3a. If yes, please mark source and amount per month, if applicable:

□Supplemental Nutrition Assistance Program (SNAP) – Food Stamps$______

□Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)$______

□TANF Child Care Services$______

□TANF transportation services$______

□Other TANF-funded services$______

□Section 8, public housing, or other ongoing rental assistance$______

□Temporary rental assistance$______

□Other source ______$______

______

Have you had any changes with your health insurance status since entering this project?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

4a. If yes, please select the type of health insurance:

□Employer-Provided Health Insurance

□Medicaid

□Medicare

□State Children’s Health Insurance Program

□Veterans Administration (VA) Medical Services

□Health Insurance obtained through COBRA

□Private Pay Health Insurance

□State Health Insurance for Adults

4b. If no, please indicate the current stage of enrollment:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

Client Refused

Are you receiving public HIV/AIDS Medical Assistance?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

**** If no, please list the reason:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

□Client Refused

______

Are you receiving AIDS Drug Assistance Program (ADAP)?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

**** If no, please list the reason:

□Applied, decision pending

□Applied, client not eligible

□Client has not applied

□Insurance type N/A for this client

□Client Doesn’t Know

□Client Refused

______

Have you had any change in disability status, documentation, or receiving treatment or services since entering this project?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

□Client Doesn’t Know

□Client Refused

HOPWA Client Exit v.2 (6-25-15)

**If yes, please select type of disability and complete extra questions:

7a. Physical Disability

-Is this Physical Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this disability?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

7b. Developmental Disability (must have developed prior to age 22)

-Is this Developmental Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this disability?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

7c. Chronic Health Condition

-Is this Chronic Health Condition expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this disability?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

7d. HIV/AIDS

-Does HIV/AIDS substantially impair your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this disability?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

7e. Mental Health Problem

-Is this Mental Health Problem expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this disability?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-How was this Mental Health Problem confirmed?

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical records

-If this is considered a Serious Mental Illness (SMI), how was that confirmed?

□Not Considered SMI

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical records

7f. Substance Abuse

□Alcohol Abuse

□Drug Abuse

□Both Alcohol and Drug Abuse

-Is this Substance Abuse Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Is the documentation of disability and severity on file or available for case worker?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-Are you currently receiving services or treatment for this condition?

HOPWA Client Exit v.2 (6-25-15)

□Yes

□No

HOPWA Client Exit v.2 (6-25-15)

-How was this Substance Abuse Disability confirmed?

□Unconfirmed: presumptive or self-reported

□Confirmed through assessment and clinical evaluation

□Confirmed by prior evaluation or clinical record