HOPWA Client Intake v.2(6/25-15)
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Client ID: ______
Update Date: ______
CoC Area Client Served: KY-501
Name: ______
FirstMiddleLast
SSN: ______-______-______Date of Birth: ____-_____-______
Veteran Status:
□Yes
□No
□Client Doesn’t Know
□Client refused to answer
______
- Zip Code of Last Permanent Address: ______
______
- Relationship to the Head of Household:
HOPWA Client Intake v.2(6/25-15)
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□Self – Head of Household
□Head of Household’s child
□Head of Household’s spouse or partner
□Head of Household’s other relation member (other relation to Head of Household other than listed)
□Other – no relation to Head of Household
HOPWA Client Intake v.2(6/25-15)
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______
- Race:
HOPWA Client Intake v.2(6/25-15)
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□White
□Black or African-American
□American Indian/Alaska Native
□Asian
□Native Hawaiian or Other Pacific Islander
□Client Doesn’t Know
□Client Refused
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______
- Ethnicity:
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□Non-Hispanic/Non-Latino
□Hispanic/Latino
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- Gender:
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□Female
□Male
□Transgender Male to Female
□Transgender Female to Male
□Other ______
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- Where did you stay last night? - Type of Living Situation:
HOPWA Client Intake v.2(6/25-15)
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□Emergency shelter, including hotel or motel paid for with 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 emergency shelter voucher
□Jail, prison, or juvenile detention facility
□Long-term care facility or nursing home
□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 habitation (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 VASH subsidy
□Rental by client, with 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 in a family member’s room, apartment, or house
□Staying or living in friend’s room, apartment or house
□Substance abuse treatment facility or detox center
□Transitional housing for homeless persons (including homeless youth)
□Other ______
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- How long did you stay there? - Length of Stay in Previous Place
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□One day or less
□Two days to one week
□More than one week, but less than one month
□One to three months
□More than three months, but less than one year
□One year or longer
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- How many times have you slept in a place not meant for human habitation or stayed in an emergency shelter in the last three (3) years?
HOPWA Client Intake v.2(6/25-15)
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□0
□1
□2
□3
□4 or more
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- Have you ever lived in a place not meant for human habitation or an emergency shelter for 365 days straight (continuously)?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client refused to answer
HOPWA Client Intake v.2(6/25-15)
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______
- Are you a domestic violence victim/survivor?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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______
- If yes, when did the last experience occur?
HOPWA Client Intake v.2(6/25-15)
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□Within the past three months
□Three to six months ago
□Six months to one year ago
□One year ago or more
□Client Doesn’t Know
□Client Refused
HOPWA Client Intake v.2(6/25-15)
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______
- Do you have any income on the day of this application?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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12a. If yes, please mark source and amount per month:
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□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 $______
□Other source: ______$______
______
- Do you have any non-cash benefits on the day of this application?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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13a. 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 ______$______
______
- Are you covered with any type of health insurance on the day of this application?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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14a. 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
14b. 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?
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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**** 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 Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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**** 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
______
- Do you have a Disability?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
□Client Doesn’t Know
□Client Refused
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**If yes, please select type of disability and complete extra questions:
17a. Physical Disability
-Is this Physical Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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17b. 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?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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17c. 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 Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Is the documentation of disability and severity on file or available for case worker?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Are you currently receiving services or treatment for this disability?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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17d. HIV/AIDS
-Does HIV/AIDS substantially impair your ability to live independently?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Are you currently receiving services or treatment for this disability?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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17e. 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 Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Are you currently receiving services or treatment for this disability?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-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
17f. 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 Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Intake v.2(6/25-15)
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-Are you currently receiving services or treatment for this condition?
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□Yes
□No
HOPWA Client Intake v.2(6/25-15)
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-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