HOPWA Client Update v.1 (6-25-14)
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Client ID: ______
Update Date: ______
CoC Area Client Served: KY-501
HOPWA Client Update v.1 (6-25-14)
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- Are you experienced domestic violence since entering this project?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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______
- If yes, when did the last experience occur?
HOPWA Client Update v.1 (6-25-14)
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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 Update v.1 (6-25-14)
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______
- Have you had any changes in your income since entering this project?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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3a. If yes, please mark source and amount per month:
HOPWA Client Update v.1 (6-25-14)
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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 $______
□ Other source: ______$______
______
- Have you had any changes in your non-cash benefits since entering this project?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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4a. 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 Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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5a. 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
5b. 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 Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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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 Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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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
______
- Have you had any change in disability status, documentation, or receiving treatment or services since entering this project?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
□ Client Doesn’t Know
□ Client Refused
HOPWA Client Update v.1 (6-25-14)
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**If yes, please select type of disability and complete extra questions:
8a. Physical Disability
- Is this Physical Disability expected to be a long-term, indefinite condition and substantially impairs your ability to live independently?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this disability?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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8b. 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 Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this disability?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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8c. 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 Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this disability?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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8d. HIV/AIDS
- Does HIV/AIDS substantially impair your ability to live independently?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this disability?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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8e. 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 Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this disability?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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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
8f. 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 Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Is the documentation of disability and severity on file or available for case worker?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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- Are you currently receiving services or treatment for this condition?
HOPWA Client Update v.1 (6-25-14)
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□ Yes
□ No
HOPWA Client Update v.1 (6-25-14)
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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