NMHMIS Program-Specific Intake Form

Short Version (required elements only)

Please answer all questions. Fill out one form for each family member at program entry.

General Information

First Name: Middle Name:

Last Name: Suffix: ______

Are You the Head of Household? q Yes q No

If No, Name of Head of Household Relationship ______

Alias Name (if applicable):______
Ever Received Services Under Different Name: q Yes q No q Don’t Know q Refused
If Yes, then provide: First Name:______Middle Name:______
Last Name: ______Suffix: ______

Date of Birth (mm/dd/yyyy): / / or: q Full q Approximate or Partial q Don’t Know q Refused

Social Security #: ______– _____ – ______q Full q Partial q Don’t Know/Don’t Have q Refused

Gender: q Male q Female q Transgender Male to Female q Transgender Female to Male q Other q Don’t Know q Refused

Ethnicity: q Non-Hispanic/Non-Latino q Hispanic/Latino q Don’t Know q Refused

Race (choose all that apply):

q American Indian or Alaska Native / q Asian / q Black or African American
q Native Hawaiian or Other Pacific Islander / q White / q Don’t Know / q Refused
For Adults (Age 18+)
Military Background:
Served/Serving U.S. Military (veteran): q Yes q No qDon’t Know q Refused
For All Individuals and All Family Members
Disabling Condition:
Do you have a disabling condition ? (to be answered by adults only after program entry, unless disabling condition is a requirement for program entry): qYes qNo qDon’t Know q Refused

HOMELESS INTAKE

Are You Homeless? (Housing Status): q Literally Homeless q Housed & at imminent risk of losing housing

q Housed and at risk of losing housing q Stably housed q Don't know q Refused

Where Did You Stay Last Night? (choose one):

q Emergency Shelter, including Hotel or Motel Paid for with an Emergency Shelter Voucher. Migrant Shelter / q Rental by Client, No Housing Subsidy
q Foster Care Home or Foster Care Group Home / q Rental by Client with VASH Housing Subsidy
q Hospital (Non-Psychiatric) / q Rental by Client with Other Housing Subsidy (Non-VASH)
q Hotel or Motel Paid for without an Emergency Shelter Voucher / q Safe Haven
q Jail or Prison / q Staying or Living in a Family Member’s Room, Apartment or House
q Juvenile Detention / q Staying or Living in a Friend’s Room, Apartment, or House
q Owned by Client, No Housing Subsidy / q Substance Abuse Treatment Facility or Detox Center
q Owned by Client, With Housing Subsidy / q Transitional Housing for Homeless Persons
q Permanent Housing for Formerly Homeless Persons / q Don’t Know
q Place Not Meant for Habitation (Car or Other Vehicle, Abandoned Building, Bus/Train/Subway Station/ Airport, Outside Anywhere, Camping) / q Refused
q Psychiatric Hospital or Other Psychiatric Facility / q Other ______

Tell Us about Your Last Permanent Address (where you last lived for 90 days or more)

Last Permanent Zip Code ______ q Full or Partial q Don’t Know q Refused

DOMESTIC ABUSE (For All Individuals and All Family Members )

Domestic Violence Victim/Survivor: q Yes q No q Don’t Know q Refused

INCOME & BENEFITS (For All Individuals and All Family Members )

Income From Work & Other Sources:
Income Received From Any Source in the Past 30 Days: q Yes q No q Don’t Know q Refused
Source of Income / Receiving Source of Income? / Amount Received
Income in dollars (i.e. employment income) / q Yes q No q Don’t Know q Refused / $______
Unemployment Insurance: / q Yes q No / $______
Supplemental Security Income (SSI): / q Yes q No / $______
Social Security Disability Income (SSDI): / q Yes q No / $______
Veteran's Disability Payment: / q Yes q No / $______
Private Disability Insurance: / q Yes q No / $______
Worker’s Compensation: / q Yes q No / $______
Temporary Assistance for Needy Families (TANF): / q Yes q No / $______
General Assistance (GA): / q Yes q No / $______
Retirement from Social Security: / q Yes q No / $______
Veteran’s Pension: / q Yes q No / $______
Pension from Former Job: / q Yes q No / $______
Child Support: / q Yes q No / $______
Alimony/Other Spousal Support: / q Yes q No / $______
Aid to the Needy and Disabled (AND): / q Yes q No / $______
Old Age Pension (OAP) / q Yes q No / $______
Other Sources:
If Other: Describe ______/ q Yes q No / $______
TOTAL MONTHLY INCOME / Monthly Income From all Sources / $______
Non-Cash Benefits (All Individuals and Family Members)
Non-Cash Benefit Received from any source in the last 30 days: q Yes q No q Don’t Know q Refused
Yes / No
Food Stamps or Money Benefits Card (Supplemental Nutrition Assistance Program (SNAP): / q / q
Food Stamps (or SNAP) Amount: $______
MEDICAID Health Insurance Program: / q / q
MEDICARE Health Insurance Program: / q / q
State Children’s Health Insurance Program: / q / q
Women, Infants and Children (WIC): / q / q
Veteran’s - VA Medical Services: / q / q
TANF Child Care Services: / q / q
TANF Transportation Services: / q / q
TANF (Other TANF-funded Services): / q / q
Section 8, Public Housing, or Other Rental Assistance or Housing Vouchers:
(Through What Agency? ______) / q / q
Other Benefit Sources: (Through What Agency?) / q / q

HEALTH - For All Individuals and All Family Members )

Health Information (For All Individuals and All Family Members )
Diagnosed HIV/AIDS: / q Yes / q No / q Don’t Know / q Refused
Substance Abuse Problem: Type of Substance Abuse Problem / q Alcohol Abuse / q Drug Abuse / q Both Alcohol and Drug Abuse / q No
(If Yes) Expected To Be of Long-Continued and Indefinite
duration and Substantially Impairs Ability to Live Independently? / q Yes / q No / q Don't Know / q Refused
Mental Health Problems: / q Yes / q No / q Don't Know / q Refused
(If Yes) Expected To Be of Long-Continued and Indefinite
duration and Substantially Impairs Ability to Live Independently? / q Yes / q No / q Don't Know / q Refused
Physical/Medical Disability: / q Yes / q No / q Don’t Know / q Refused
Developmental Disability: / q Yes / q No / q Don’t Know / q Refused
FOR AGENCY USE ONLY: Go to Household Tab to Add Additional Family Members

(FOR AGENCY USE ONLY)

If enrolling in // exiting out of housing program:
1. Program Name: ______
Entry Date: ____/ _____/ ______(if enrolling)
Exit Date: ____/ _____/ ______(if exiting. Leave blank if client not exiting out of program)
/ If exiting from program:
Destination (choose one):
q Deceased / q Don’t Know
q Emergency shelter, including hotel or motel paid for with Emergency Shelter voucher / q Foster care home or foster care group home
q Hospital (non-psychiatric) / q Hotel or motel paid for without emergency shelter voucher
q Jail, prison or juvenile detention facility / q Other (Please specify)
______
______
q Owned by client, no housing subsidy / q Owned by client, with housing subsidy
q Permanent supportive housing for formerly homeless persons (such as SHP, S+C, or SRO Mod Rehab) / q Place not meant for habitation (e.g. , a vehicle or anywhere outside)
q Psychiatric hospital or other psychiatric facility / q Refused
q Rental by client, no housing subsidy / q Rental by client, other (non-VASH) housing subsidy
q Rental by client, VASH Subsidy / q Safe Haven
q Staying or living with family, permanent tenure / q Staying or living with family, temporary tenure
q Staying or living with friends, permanent tenure / q Staying or living with friends, temporary tenure
q Substance abuse treatment facility or detox center / q Transitional housing for homeless persons (including homeless youth)
If providing service(s):
Service Name # 1: ______
______
Entry Date: _____/ ____/ ______
Exit Date: _____/ ____/______
Status: Closed, Identified, or in Progress (check one)
#Units: ______
If providing service(s):
Service Name # 2: ______
______
Entry Date: _____/ ____/ ______
Exit Date: _____/ ____/______
Status: Closed, Identified, or in Progress (check one)
#Units: ______

Please copy additional pages as required.

NM HMIS Program-Specific Intake Form ver. April 19, 2012

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