RHY HMIS Standard Intake Form Effective 10/01/2016

Project Name:______Entry:ServicePointID:EntryType:

First:Middle:

Last:Suffix: Alias:

Social Security Number:

Page 1 of 3

FullSSN / Approximate or PartialSSN
Client doesn’tknow / Clientrefused
Household Information
Singleadult,
no children / Female single parent / Male singleparent / Couple with
no children
Two parentfamily with children / Couple (parent and friend) andchildren / Foster parent(s) andchildren / Grandparent(s) andchildren

Non-custodialcaregiver(s) Other:

Relationship to Head of Household:
Self (Head ofHousehold) / HoH’s child / HoH’s spouse orpartner
HoH’s other relationmember / Other: non-relationmember


Education
What is the highest level of school that you have completed?
Less than Grade5 / Grades5-6 / Grades7-8 / Grades9-11
Grade12 / School program does nothave gradelevels / GED / Somecollege
Associatesdegree / Bachelor’sdegree / Graduatedegree / Vocationalcertification
Client doesn’tknow / Clientrefused
Employment
Are you presently employed?
No / Yes / Client doesn’tknow / Clientrefused
If employed, is this permanent, temporary or seasonal work?
Full-time / Part-time / Seasonal / Client doesn’tknow
Clientrefused

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RHY HMIS Standard IntakeForm

Residence Prior toProjectEntry(Where did you stay lastnight?)
Homeless Situation / Transitional and Permanent Housing
Place not meant for habitation (e.g. vehicle, aban- doned building, bus/train/subway station/airport or anywhereoutside)
Emergency Shelter (including hotel or motel paid for with an emergency sheltervoucher)
SafeHaven
InterimHousing / Hotel or motel paid for without emergency sheltervoucher
Owned by client, no ongoing housingsubsidy
Owned by client, with ongoing housingsubsidy
Permanent housing for formerly homeless persons (CoCproject; HUD legacy programs; or HOPWA PH, or RapidRe-housing)
Rental by client, no ongoing housingsubsidy
Rental by client, with VASHsubsidy / Rental by client, with GPD TIP (transition- in-place)subsidy
Residential project or halfway house with no homelesscriteria
Staying or living in a FAMILY member’s room, apartment orhouse
Staying or living in a FRIEND’S member’s room, apartment orhouse
Transitional housing for homeless per- sons (including homelessyouth)
Institutional Situation / Unknown
Foster care home or foster care grouphome
Hospital or other residential non-psychiatric medicalfacility
Jail, prison or juvenile detentionfacility
Long-term care facility or nursinghome / Client doesn’tknow
Clientrefused



Domestic Violence
Are you, or have you been a survivor of domestic or intimate partner violence?
No / Yes
Client doesn’tknow / Clientrefused
If YES, how long ago did you have this experience?
Within the past 3months / 1 year agoormore
3 to 6 monthsago / 6 months to 1 yearago
Client doesn’tknow / Clientrefused
If Yes , are you currently fleeing ?
No / Yes
Client doesn’tknow / Clientrefused

RHY HMIS Standard Intake Form

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Income
No/None atall / Yes (Identify source andamounts)
Client doesn’tknow / Clientrefused
Source: / Amount:
Earned income (i.e., employmentincome) / $.00
UnemploymentInsurance / $.00
Supplemental Security Income(SSI) / $.00
Social Security Disability Income(SSDI) / $.00
Retirement Income from SocialSecurity / $.00
VA Service-Connected DisabilityCompensation / $.00
VA Non-Service-Connected DisabilityPension / $.00
Worker’sCompensation / $.00
Temporary Assistance for Needy Families(TANF) / $.00
General Assistance(GA) / $.00
Private disabilityInsurance / $.00
Pension or retirement income from a formerjob / $.00
ChildSupport / $.00
Alimony or other spousalsupport / $.00
Othersource: / $.00
Total Monthly Income: / $

Disability

Do you have a physical, mental or emotional impairment, a post-traumatic stress disorder, or brain injury; a developmental disability, HIV/AIDS, or a diagnosable substance abuse problem?

Client refused


Physical / 
Mental Health / 
Chronic Health Condition / Alcohol
Drugs
Both / 
Developmental / 
HIV/AIDS
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently: / Yes / Yes / Yes / Yes / N/A / N/A
Expected to substan- tially impair ability to live independently: / N/A / N/A / N/A / N/A / Yes / Yes
Documentation of the disability and severity on file: / Yes / Yes / Yes / Yes / Yes / Yes
Currently receiving services/treatment for this disability: / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused / No
Yes
Clientdoesn’tknow
Clientrefused
Staff Completing (Printed Name): / Date: