River Valleys Continuum of Care Coordinated Intake and Assessment System

HomelessnessDiversion and PreventionScreening Tool

Date: Interviewer’s Initials:______

DIVERSION SCREEN

  1. Are you safe in your current living situation? Yes: No (If no, refer or admit to Emergency Shelter)
  1. Where did you stay last night?(check one)

Outside/Park/Campground / Emergency or DV Shelter / Own Apartment/House/Trailer
Shed/Garage or Outbuilding / Motel Paid by Agency / With a Family Member or Friend
Vehicle / Hospital or Treatment Facility / Motel Paid by Self, Family, Friend
Public Building or Skyway / Jail, Prison or Detention / Other:
Refer to emergency shelter and/or assessment site to complete VI-SPDAT / Continue with screening
  1. If you are currently housed, what are the reasons you cannot stay in your current housing situation?

Late Rent / If checked, refer to appropriate mainstream resource to attempt prevention/diversion.
3 Day Notice to Evict
Court Eviction or Foreclosure
Utility Shut-Off
Problems with Landlord
Domestic Violence/Sexual Violence
Overcrowding
Other:
  1. How long are you able to stay in your current housing situation?

Can nolonger stay there / If checked, go to question #5.
2-7 Days / If checked, refer to appropriate mainstream resources to attempt prevention/diversion.
1-3 Weeks
Indefinite/Unknown
  1. Is there anyone else you could stay with for the next 3-7 days if you were able to receive case management, transportation or other limited financial support? Yes No

NO / Yes
If no, refer to emergency shelter. / If yes, please list where:
What resources would you need to stay there?

Head of Household Name: ______Date of Birth______

Number of people in Household (including household head): ______

CONTACT INFO: Where can we contact you to make follow-up referrals or obtain additional eligibility information?

Address:______

Street City State Zip

Phone #: ( ) - Message #: ( ) - Email:______

Results of Screening:______

PREVENTION SCREEN

  1. How long have you been staying in your current housing situation? ______
  1. Do you have a current crisis that has or will jeopardize your housing? Yes No

If yes, what is the crisis?______If yes, date of occurrence:______

  1. Have you been homeless before? Yes, answer Homeless History section. No, proceed to question #3.

Yes / No / HOMELESS HISTORY
Have you ever stayed at a shelter or in housing program before?
If yes, list programs and dates.______
Were you homeless in the past 12 months?
Have you been continuously homeless for over a year?
Have you had four (4) or more separate episodes of homelessness in the past three (3) years?
  1. Do you believe you will become homeless in the next 14 days? Yes No
  1. Do you or anyone in your household have a disability? Yes No

If yes, does your disability affect your ability to seek or maintain housing or employment? Yes No

  1. Do you have any of the following barriers that make it difficult to find housing? (check all that apply)

Yes / No / HOUSING BARRIERS
Criminal History
Previous Evictions
Poor or No Rental History
Poor or No Credit
Past Due Rent/Utilities
Large Family (4 bedroom +)
  1. Are you pregnant or is there anyone under the age of 18 in your household? Yes No
  1. Do you currently have a housing voucher or subsidy to help you pay rent each month? Yes No
  1. Do you currently or have you ever served on active duty in the United States Armed Forces? Yes No

If yes, are you willing to be join the Minnesota Veterans Registry? If yes, go to the registry via the link below.

  1. Do you have any source of monthly income? If so please list income sources and total amount:

Yes / No / Source / Amount (Monthly)
Employment
Unemployment
Child Support
SSI/SSDI
TANF/MFIP
General Assistance
Retirement
Veterans Benefits
Tribal Funds
Other:
  1. Does anyone in your family currently have a case manager or worker? No Yes, please list

Name:______Agency:______

Name:______Agency:______

Results of Screening:______

Optional

FOR OFFICE USE ONLY:

Household Name:______

Total Prevention Points:______(Questions 2-8 Prevention Screen)

VI-SPDAT Score (if applicable):______

Does the household qualify for prevention assistance? Yes No

Does the household qualify for diversion assistance? Yes No?

Is the household automatically qualified for homeless assistance (currently homeless with a voucher)? Yes No

If yes, what kind of assistance do they need initially to be successfully housed?

Landlord Mediation Rental Assistance: $ ______

Utility Assistance: $ ______Other Financial Assistance: $ ______

Other Assistance:$ ______

Follow Up:

  1. Was the household diverted from entering the shelter? Yes No

If yes, to where? Friends Family Previous Housing Other: ______

If no, date entered shelter: ______

  1. Was the household prevented from becoming homeless? Yes No
  1. If the household was homeless at intake, were they able to obtain housing? Yes No

If no, what was the primary barrier that prevented them from obtaining housing?

Unable to locate a unit Programs at capacity Ineligible for program

Household left the area Other______

  1. Did the household receive financial assistance? Yes No

If yes, what type?

Utility Assistance: $______Rental Assistance:$______Moving Costs:$______

Security Deposit:$______Other: ______

After 30 days: Did they find or maintain permanent housing? Yes No

After 90 days: Have they come back to shelter/the homeless assistance system since they were assisted? Yes No

Are there whereabouts known? Yes No

If yes, where do they live currently?

Remained in initial housing

Relocated to different permanent housing unit

In homeless assistance system

Other: ______

If they “remained in initial housing” or “relocated to different permanent housing unit” how long have they been there?

Number of days: ______

12/8/2014