CES Survey - LAHSA Documents
Greater Los Angeles Coordinated Entry System Survey Packet Version 1.1 CES Survey: Introduction Thank you for taking time to know the name and needs of our homeless neighbors. The 20-30 minutes you will spend are invaluable to helping us understand the unique needs of the respondent and also the broader region in which he/she resides. Your engagement of the respondent and effective application of the following survey is a critical first step to ending homelessness in Greater Los Angeles. Thank you! CONTENTS 1. Instructions (for Surveyor): Brief guidelines for best application of this survey - further instructions are available electronically on the CES Website @ www.HomeForGoodLA.org/ces (VI-SPDAT Manual & Webinar) and inperson via periodic trainings. 2. Checklist: A list of the steps involved in making the respondent eligible for referrals through CES. 3. Instructions (for Respondent): A script of instructions to be read aloud to the respondent. 4. Consent: Required form to gain legal permission to share respondent answers in the shared database. 5. Part 1 (VI-SPDAT & Intake) Part 1 of the CES Survey features the Vulnerability Index-Service Prioritization Decision Assistance Tool (VISPDAT). The VI-SPDAT is a triage tool designed to recommend the best type of permanent housing solution for someone experiencing homelessness. It is a holistic survey developed by OrgCode Consulting and Community Solutions and is written in a manner designed to be understood more easily by respondents. Part 1 of the survey also includes a set of basic intake and eligibility questions to help begin identifying resources and supports that the respondent may qualify for immediately. 6. Part 2 (Housing Preferences) Part 2 of the CES Survey completes the set of eligibility questions that are used to help make more appropriate referrals to housing opportunities. This was formerly known as the Matching Initiation Form. While you may choose to complete this portion with the respondent at a later time, many of the permanent housing resources available through CES require both Parts 1 & 2 (along with document collection) to be complete before referrals are generated. 7. Contact Sheet: A sheet with follow-up contacts that you may wish to provide the respondent upon request. 8. Additional Consents (*If Provided): Additional authorization, release and consent forms may be provided by your agency or coordinator to allow for seamless coordination with other supports or resources. INSTRUCTIONS FOR THE SURVEYOR **Please do not read aloud** THE CONSENT MUST BE COMPLETED AND SIGNED (FOR HOUSEHOLDS, EVERY ADULT MEMBER MUST SIGN) In the case that respondent refuses consent, you may still proceed, however please note these special instructions: Do not enter Personal Identifiable Information (PII) into HMIS. HMIS will automatically generate an anonymous ID. Please retain at least the first page of CES Survey Part I (with HMIS ID & Client Name) for your records and future matches since you will not be required to enter identifying information into HMIS. DO NOT BE DISAPPOINTED IF THE RESPONDENT DOESN’T WANT TO BE SURVEYED. Negative experiences with past services may cause the respondent to be distrustful. Reversing course on that is a process, and your positive interaction and respect of their boundaries will help future engagements. DO NOT PROMISE HOUSING OR SERVICES. Though you may be trying to be helpful, false promises will only add to their distrust and disinterest with future engagements. Version 1.1 Introduction: Page 1 of 3 Modified 3/19/2015 CES Survey: Introduction DO NOT MANIPULATE RESPONSES. Major eligibility criteria are officially verified later so it does not benefit the respondent to be dishonest. Also, don’t be concerned if the respondent isn’t noting some issues that are clearly visible - the “Observation” questions will balance the responses for several sections. DO NOT VOLUNTEER THE SCORE OR THE SCORING PROCESS. You may share the general housing recommendation, but we do not want people being referred to as numbers. YES AND NO ANSWERS ARE FINE, IDEAL EVEN. AVOID FOLLOW UP QUESTIONS. Respondents do not need to explain themselves. Explain questions if further clarification is needed, but try to keep the conversation short and clear to respect their time. Make note of items you may want to come back to, but allow engagement/case management to happen separate from the survey itself. COUNT BACKWARDS AND PAUSE. For any question that asks a date range, count backward to the first date – so if today is January 1, 2015 and the questions asks “in the last 6 months,” say in “in the last 6 months…December, November, October, September, August, July. So since July 2014 …” Also, for any question that states “anything like that,” add an intentional pause between “or anything (pause) like (pause) that” to help emphasize that you have read a list. BE PREPARED TO EXPLAIN LENGTH OR QUESTIONS If a respondent finds a question offensive or is frustrated by the length, please explain that each question will help to avoid some inappropriate referrals and hopefully save them time in the long run. For other questions with more obvious answers, you may explain that you wanted to give them the ability to speak for themselves. PRACTICE. As you become more comfortable with the survey, you should notice a gradual reduction in the amount of time it takes to complete. CHECKLIST Prepare Review: Instructions for the Surveyor Read Aloud: Instructions for the Respondent Request Signature: Consent Form Survey Verbally Administer: Survey Part 1 (VI-SPDAT & Intake) Verbally Administer: Survey Part 2 (Housing Preference) Survey Part 1 and 2 may be completed at separate times; however, both are needed to complete a client record. Take picture: Client may decline. Ask if you can take a picture of their ID instead or take a picture with them. Provide: Contact sheet if you or your coordinator are willing to be available for follow-up contact Follow-Up File Consent: Keep record of consent and/or distribute to appropriate party in your SPA Data Entry: Enter survey responses into HMIS Upload: client picture, copies of documents, additional signed consents, to HMIS ================The following steps may be taken over by a Housing Navigator======================= Obtain Documents (*if not already in possession): Birth Certificate, ID & Social Security. Although not immediately required, please be prepared to quickly prepare income verification documents as well. Possessing documents required for housing is the final step in becoming “match-ready” for most housing in CES. Data Entry: Note receipt of documents and upload scanned copy of documents into HMIS if possible. Version 1.1 Introduction: Page 2 of 3 Modified 3/19/2015 CES Survey: Introduction INSTRUCTIONS FOR RESPONDENT Hello! My name is ______________ and I am with a group called_______________ (organization name). I have a survey I would like to complete with you. There are two parts to this survey, and it’ll take about 25-30 minutes to complete. Most questions only require a “yes,” “no” or other one-word answer. If you have more to share about an answer, I’d be happy to discuss that after the survey, but it’s important that we finish this first. While this is not a housing application, the answers will help us understand your health and housing needs and the needs of our community, and may help us make better referrals for you in the future. All that to say, I’m not using the answers you give to make any personal judgments about you. This survey is for anyone who is experiencing homelessness – not just people with a certain type of need. Some questions are personal in nature, but again, every question is designed to help us help you. You can skip or refuse any question that you don’t feel comfortable answering, but the more questions you’re willing to answer, the better. Someone may follow up with you to assist in getting documents needed to access resources, so it’s important that we have accurate contact information for you. There is no need to take this survey twice, but from time to time we may want to update it with you, to make sure the information is accurate. Afterward, you may request a contact sheet and refer to it if you have questions. Before we begin, I need to get your permission to do this survey with you. Please review the following form and let me know if you have any questions. Version 1.1 Introduction: Page 3 of 3 Modified 3/19/2015 CES Survey: Consent Los Angeles & Orange County Homeless Management Information System (LA/OC HMIS) Collaborative and Participating Organizations Client Consent to Provide and Disclose Information ________________________________________________________________________________________ The LA/OC Homeless Management Information System (HMIS) is a local electronic database that securely records information (data) about clients accessing housing and homeless services within the Los Angeles and Orange Counties. This organization participates in the HMIS and shares information with other organizations that use this database. This information is utilized to provide supportive services to you and your household. What type of information may be shared in the HMIS? We collect general and Protected Personal Information about you. This includes but is not limited to: Your name and your contact information Your social security number Your birthdate Your basic demographic information such as gender and race/ethnicity Your history of homelessness and housing (including your current housing status and where and when you have accessed services) Your self-reported medical history including any mental health and substance abuse issues Your case notes and services Your case manager's contact information Your income sources and amounts; and non-cash benefits Your veteran status Your disability status Your household composition Your emergency contact information Any domestic violence history Your photo, if you choose to provide How do you benefit from providing your information? The information you provide for the HMIS helps us coordinate the most effective services for you and/or your family. By sharing your information, you may be able to avoid being screened more than once, get faster services, and minimize how many times you have to tell your ‘story.’ Collecting this information also gives us a better understanding of homelessness in your local area and the effectiveness of the services provided in your area. Who can have access to your information? The LA/OC Collaborative organizations and other participating organizations can have access to your data. These organizations may include homeless service providers, other social services organizations, housing groups, and healthcare providers. All participating organizations who have access to your information have signed an agreement to maintain the security and confidentiality of your information. How is your personal information protected? Your information in the HMIS is protected by passwords and encryption technology. In addition, each participating organization must sign an agreement to maintain the security and confidentiality of the information. Any person or participating organization that violates the agreement may have their access rights terminated and may be subject to further penalties. Version 1.1 Consent: Page 1 of 2 Modified 3/19/2015 CES Survey: Consent By signing below, you understand that: You have the right to receive services even if you do not sign this consent form. Your consent permits any participating organization to update your information in HMIS without asking you to sign another consent form. You may cancel your consent at any time, but your cancellation must be done either in writing or by completing the Client Revocation of Consent to Provide and Disclose Information form. Upon receipt of your revocation, the Protected Personal Information that you previously authorized to be placed in the HMIS will be de-identified. The LA/OC HMIS Privacy Notice contains more detailed information about how your information may be used and disclosed. Upon your request, we will provide you with: o A copy of this form o A copy of the LA/OC HMIS Privacy Notice o A copy of your HMIS records within five (5) business days of your request o A current list of participating organizations that have access to your data Aggregate or statistical data that is released will not disclose any of your Protected Personal Information. This consent is valid for seven (7) years from the date you sign below You have the right to file a grievance against any organization whether or not you sign this consent You are not waiving any rights protected under Federal and/or California law SIGNATURE AND ACKNOWLEDGEMENT Your signature below indicates that you have read (or been read) this client consent form, have received answers to your questions, and you freely consent to have your information, and that of your minor children (if any), entered into the LA/OC HMIS. You also consent to share your information with other organizations as described on page one of this form. Client Name: ________________________ DOB: _____________ Last 4 digits of SS_________ Signature ___________________________________________ Date ______________________ Head of Household (Check here) Minor Children (if any): Client Name: ________________________ DOB: _____________ Last 4 digits of SS_________ Client Name: ________________________ DOB: _____________ Last 4 digits of SS_________ Client Name: ________________________ DOB: _____________ Last 4 digits of SS_________ Client Name: ________________________ DOB: _____________ Last 4 digits of SS_________ ____________________________________________ Print Name of Organization _______________________________ Print Name of Organization Staff ____________________________________________ Signature of Organization Staff _______________________________ Date Version 1.1 Consent: Page 2 of 2 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Instructions for Respondent: PLEASE READ ALOUD The first part of this survey will help us learn more about you, your situation, and your needs. Again, I know that some people tell others what they want them to hear, rather than telling them the truth. It’s up to you, but the more honest you are, the better we can figure out how best to support you. Also, keep in mind that since eligibility requirements will be verified later, it’s best to answer as honestly as you can. If at any point you don't understand what I am asking, just let me know. I’ll give you a moment to gather your thoughts, and we’ll get started with the first question... **wait 15 seconds before proceeding** (even though this is awkward, this will help the respondent mentally prepare) Identification (All fields required unless otherwise noted) First Name: ___________________________________ Middle Name (Optional): _____________________________________ Last Name: ___________________________________ Suffix (Optional): _____ Name Data Quality: Did the client provide their full name? Full Name Reported Partial, street name, or code name reported Client Doesn’t Know Client Refused Data not Collected Date of Birth: ________/________/________ Full DOB reported Approximate or partial DOB reported Client Doesn’t Know Client Refused Data not Collected HMIS consent signed? Yes Refused Physical Description (Optional): Last Known Permanent Address: Where have you last lived for 90 days or more? (Not including emergency shelters and transitional housing) Address: City: County: SSN: State: _________-_______-__________ Full SSN reported Zip: Approximate or partial SSN reported Client Doesn’t Know Address Client Refused Quality: Data not Collected __________ Full Address Reported Client Doesn’t Know Incomplete or Estimated Client Refused Address Reported Data not Collected Contact Information (Optional but extremely helpful) Phone Number (Do you have a number and email where I can follow-up with you or leave a message?) Main: (______)______-_________ x______ Leave message Alternate:(______)______-_________ x______ Leave message Email Version 1.1 ______________________@____________ Phone Type Home Cell Home Cell Contact Preference Work Message Center Work Message Center Phone Text Email Notes Survey Part 1: Page 1 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Contact Type Alternate Contact (Who is the best person to get in touch with you?) Relationship: _______________ First Name: _______________ Last Name: _______________ Emergency Contact (In case of an emergency, who should we alert?) Same as above Relationship: _______________ First Name: _______________ Last Name: _______________ Phone Number (______)______-_________ x______ (______)______-_________ x______ Client Name / HMIS ID: _____________________ Phone Type Email Home Cell Work Message Center Home Cell Work Message Center Location Information (Optional) Location Type: On a regular day, where is it easiest to find you? Street Vehicle Abandoned building Bus/train/subway station/airport Drop in center Day services center Soup kitchen Emergency Shelter Transitional Housing Permanent Housing Clinic/Hospital - Health Clinic/Hospital – Mental Health Clinic/Hospital – Substance Abuse Jail, prison, or juvenile detention facility Family or friend’s room, apartment, condo, or house Foster care or group home What times of day could we find you there? (Select all that apply) Address Type (Enter one: Address, Intersection, or Landmark): Address: Intersection: and Landmark: ____________________________________________ City, County, State, and Zip (Enter all): City: County: State: Zip: Zip Quality: Early morning (6am – 9 am) Late morning (9am – 12pm) Early afternoon (12pm-2pm) __________ Full or Partial Client Doesn’t Know Late afternoon (2pm – 4pm) Early evening (4pm – 6pm) Evening (6pm – 12 am) Client Refused Data not Collected Overnight (12 am-6am) Client Doesn’t Know Client Refused Outreach Contact Details (For outreach programs only, all fields required unless otherwise noted) Staff Name Contact Date/Time Program # of Clients Notes (use case note section at end) SURVEYOR ONLY – DO NOT ASK: Was the client referred to you, or were you requested to contact the client? Referral Information (Required only for referred clients and requests) Date & Time Referral First Name Referral Type Phone Email Walk-In Referral Last Name Referral Source Email Referral Organization Phone Version 1.1 Survey Part 1: Page 2 of 19 Yes No Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Demographics (All fields required unless otherwise noted) Housing Status: Category 1 - Homeless Category 2 – At Imminent Risk of Losing Housing (within 14 days or less) Category 3 – Homeless only under other Federal Statutes Category 4 – Fleeing Domestic Violence At Risk of Homelessness Stably Housed TB Clearance Date (Optional) Ethnicity Non-Hispanic Gender: Male Client Doesn’t Know Female Client Refused Transgender Female to Male Data not Collected Transgender Male to Female Other (Specify:_________________________) Have you ever served What is the highest level of education you’ve completed? Race in the U.S. Military? (Check All that (Veteran) Apply) Yes* No Client Doesn’t Know Client Refused Data not Collected *If yes, please administer VA release of information Hispanic Residency Status Citizen Permanent Legal Resident Version 1.1 Client Doesn’t Know Client Refused Data not Collected Clinic Providing Clearance (Optional) Relation (to Head of Household completing survey) Self (Head of household/not part of household) Head of Household’s Child Head of Household’s Spouse or Partner Head of Household’s other Relation Member Other: Non-relation Member (i.e. unrelated) Are you disabled? (Physical, Developmental, Mental Health, Chronic Health Condition, HIV/AIDS, and/or Substance Use Disorder.) Yes No Client Doesn’t Know Client Refused Data not Collected Family Type: Unaccompanied Single Parent Two Parents Adults No children No Schooling Completed Nursery School to 4th Grade 5th or 6th Grade 7th or 8th Grade 9th Grade 10th Grade 11th Grade Data not Collected 12th Grade, no diploma High School Diploma GED Post-Secondary School 4-year College Degree Graduate School Unknown Client Doesn’t Know Asylee, Refugee, or other Eligible Immigrant Ineligible Immigrant Survey Part 1: Page 3 of 19 Asian Black or AfricanAmerican Native Hawaiian or Other Pacific Islander American Indian or Alaska Native White Client Refused Client Doesn’t Know Client Refused Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Income and Insurance (All fields required unless otherwise noted) DPSS ID (Optional): ________________ GAIN Participant (Optional) Income Source (Check all that apply): Stated Income: Pay Interval: How often do you get it? What sources of income do you have? If you received How much do Every Twice housing, how would you pay for things like food and you get? Weekly Other A Monthly Quarterly Yearly utilities? Week Month $ No financial resources $ Earned Income (employment wages / cash) $ 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 $ Workers Compensation Temporary Assistance for Needy Families (CalWorks) $ $ General Assistance (GA) / General Relief (GR) $ Retirement Income from Social Security $ Pension or retirement income from a former job $ Child Support $ Alimony and other spousal support $ Other Source (Specify:_____________________) Client Doesn’t Know Client Refused Data not Collected Income Documentation (Optional): Do you have documents that verify those amounts? Comments (Optional): GR Form CalWORKs Form Pension Letter/Stub Pay Stub Unemployment Insurance Forms Unemployment Forms Utility Allowance W-2 Forms Self Declaration Child Support Forms SSDI Form Employer Printout/Letter Social Security Forms Workmans Comp VA Documentation SSI Forms Self Employment Docs Non-Cash Benefits (Check all that apply): What non-cash benefits do you receive? None Client Doesn’t Know Client Refused Food Stamps (CalFresh) CalWorks Child Care Temporary Rental Assistance Amount: __________ CalWorks Transportation Section 8 or Rental Assistance WIC Other CalWorks-Funded Services Other ___________________ Health Insurance (Check all that apply): No Health Insurance Client Doesn’t Know MEDICAID MEDICARE Employer Provided Health Ins. COBRA Health Ins. Client Refused State Children’s Health Ins. Private Pay Health Ins. Health Insurance Provider (Check all that apply): HealthNet Anthem Blue Cross Kaiser Permanente L.A. Care L.A. Care Health Plan L.A. Care Health Partners Version 1.1 Survey Part 1: Page 4 of 19 VA Care 1st Health Plan Data not Collected Medically Needy Amount: _________ Data not Collected VA Medical Services MediCal Other Unknown None Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Documentation (Optional) (Check all that are in the client’s possession) Expiration Date: (If applicable) Birth Certificate Certificate of Disability DD214 (Veterans Only) Driver’s License / CA ID Homeless Verification Proof of Residency Reference Letter Social Security Card TB Certification Verification of Income VA Release LACDMH 677 Authorization Consent DHS Pre-release Other: Version 1.1 Survey Part 1: Page 5 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Program Entry (All fields required unless otherwise noted) Program Name: ________________________________________ Consent: System Program Entry Date: _____/_____/_____ Case Manager: ________________________________ HOMELESSNESS - Adults aged 18 and older and Head of Household < 18 years old, required questions are shaded Question 1. Where did you sleep last night? Check One Answer Comments Emergency shelter Foster care home or foster care group home Hospital or other residential non-psychiatric medical facility** Hotel or motel paid for with emergency shelter voucher 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 Place not meant for habitation (street, car, bus, riverbed, etc) Psychiatric hospital or other psychiatric facility** Rental by client, no ongoing housing subsidy Rental by client, with VASH housing subsidy Rental by client, with GPD TIP subsidy Rental by client, with other (non-VASH) 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 a friend’s room, apartment or house Substance abuse treatment facility or detox center** Transitional housing for homeless persons Other (Specify:_______________________________________) Client Doesn't Know Client Refused Data not Collected 2. How long have you been staying at the One day or less** More than three months, but place where you slept last night? less than one year Two days to one week** (How long was your stay?) One year or longer More than one week, but less than one month** Client Doesn't Know One to three months** Client Refused Data not Collected If question #2 was answered as three months or less (**) AND question #1 was answered as one of the following (**): -“Hospital or other residential non-psychiatric medical facility” -“Jail, prison or juvenile detention facility” -“Psychiatric hospital or other psychiatric facility” -“Substance abuse treatment facility or detox center” Then the following question is required: 2a. Where were you sleeping prior Emergency shelter to entering the institutional setting Foster care home or foster care group home mentioned above (in question #1)? Hospital or other residential non-psychiatric medical facility Hotel or motel paid for without emergency shelter voucher Jail, prison or juvenile detention facility Continued on Next Page Version 1.1 Survey Part 1: Page 6 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ 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 Place not meant for habitation Psychiatric hospital or other psychiatric facility Rental by client, no ongoing housing subsidy Rental by client, with VASH housing subsidy Rental by client, with GPD TIP subsidy Rental by client, with other (non-VASH) 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 a friend’s room, apartment or house Substance abuse treatment facility or detox center Transitional housing for homeless persons Other Client Doesn't Know Client Refused Data not Collected 3. Have you been continuously homeless No Client Doesn’t Know for at least one year? Yes Client Refused Data not Collected 4. In the past three years, how many times 0 (not homeless - Prevention only) Client Doesn’t Know have you been housed then homeless 1 (homeless only this time) Client Refused again? 2 Data not Collected (How many times have you been homeless 3 in the past three years?) 4 or more** If question #4 was answered as “4 or more” (**), then the following question is required: 4a. Total number of months 0 7 Client Doesn’t Know homeless in the past three years? 1 8 Client Refused 2 9 Data not Collected 3 10 4 11 5 12 6 More than 12 months 5. How many months have you been homeless during this current period of being homeless? (Total number of months ____________ Months continuously homeless immediately prior to today) 6. STAFF ONLY – DO NOT ASK: Has the Yes client’s homeless status been verified? No (Status Documented) HISTORY OF HOUSING & HOMELESSNESS - VI-SPDAT, required questions are shaded Question 7. How many months have you lived on the streets or in shelters? (in total during lifetime) Version 1.1 Comments ________ Months Survey Part 1: Page 7 of 19 Client Doesn’t Know Client Refused Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ RISKS - VI-SPDAT, required questions are shaded SCRIPT: I am going to ask you some questions about your interactions with health and emergency services. If you need any help figuring out when six months ago was, just let me know. Question Check One Answer (*when applicable) Comments 8. In the past six months, how many times have Client Doesn’t Know ________ you been to the emergency department/room? Client Refused Client Doesn’t Know 9. In the past six months, how many times have ________ you had an interaction with the police? Client Refused 10. In the past six months, how many times Client Doesn’t Know have you been taken to the hospital in an Client Refused ________ ambulance? *Please note that this includes psychiatric facilities as well. 11. In the past six months, how many times Client Doesn’t Know have you been hospitalized as an in-patient, Client Refused ________ including hospitalizations in a mental health hospital? 12. In the past six months, how many times Client Doesn’t Know have you used a crisis service, including ________ Client Refused distress centers or suicide prevention hotlines? 13. Have you been attacked or beaten up since No Client Doesn’t Know becoming homeless? Yes Client Refused No Client Doesn’t Know 14. Have you threatened to or tried to harm yourself or anyone else in the last year? Yes Client Refused 15. Do you have any legal stuff going on right No Client Doesn’t Know now that may result in you being locked up or Yes Client Refused having to pay fines? 16. Does anybody force or trick you to do things No Client Doesn’t Know that you do not want to do? Yes Client Refused 17. Ever do things that may be considered to be No Client Doesn’t Know risky like exchange sex for money, run drugs for Yes Client Refused someone, have unprotected sex with someone you don’t really know, share a needle, or anything like that? 18. I am going to read types of places people Shelter Client Doesn’t Know sleep. Please tell me which one that you sleep Street, Sidewalk or Doorway Client Refused at most often. (Check only one.) Car, Van or RV Bus or Subway Beach, Riverbed or Park Other (specify in comment) SOCIALIZATION & DAILY FUNCTIONS - VI-SPDAT, required questions are shaded Question 19. Is there anybody that thinks you owe them money? 20. Do you have any money coming in on a regular basis, like a job or government benefit or even working under the table, dumpster diving or bottle collecting, sex work, odd jobs, day labor, or anything like that? Version 1.1 Check One Answer No Yes Client Doesn’t Know Client Refused No Yes Client Doesn’t Know Client Refused Survey Part 1: Page 8 of 19 Comments Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) 21. Do you have enough money to meet all of your expenses on a monthly basis? Do you have enough to cover what you need each month? 22. Do you have planned activities each day other than just surviving that bring you happiness and fulfillment? 23. Do you have any friends, family or other people in your life out of convenience or necessity, but you do not like their company? 24. Do any friends, family or other people in your life ever take your money, borrow cigarettes, use your drugs, drink your alcohol, or get you to do things you really don’t want to do? 25. OBSERVATION ONLY – DO NOT ASK: Surveyor, do you detect signs of poor hygiene or daily living skills? Client Name / HMIS ID: _____________________ No Yes Client Doesn’t Know Client Refused No Yes Client Doesn’t Know Client Refused No Yes Client Doesn’t Know Client Refused No Yes Client Doesn’t Know Client Refused No Yes WELLNESS - VI-SPDAT, required questions are shaded Question Comments 26. Where do you usually go for healthcare or when you’re not feeling well? (Check all that apply; answer may come up later in DHS quest) Hospital Clinic VA Other (specify in comments) Does not go for care Client Doesn’t Know Client Refused 26a. What is the name of that place? (Again, answer may come up later too) _______________________ Client Doesn’t Know Client Refused SCRIPT: Do you have now, have you ever had, or has a healthcare provider ever told you that you have any of the following medical conditions: Question Check One Answer No Client Doesn’t Know 27. Kidney disease/End Stage Renal Disease or Dialysis Yes Client Refused No Client Doesn’t Know 28. History of frostbite, Hypothermia, or Immersion Foot Yes Client Refused No Client Doesn’t Know 29. Liver disease, Cirrhosis, or End-Stage Liver Disease Yes Client Refused Client Doesn’t Know 30. Have you been diagnosed with AIDS or have you tested positive No Client Refused for HIV? Yes** Data not Collected If question #30 was answered as “Yes” (**), then the following questions are required: Client Doesn’t Know 30a. Do you expect this to substantially impair your ability No Client Refused to live independently? Yes Data not Collected 30b. Do you have documentation of the disability and No severity on file? Yes Client Doesn’t Know 30c. Are you currently receiving services or treatment for No Client Refused this condition? Yes Data not Collected Version 1.1 Survey Part 1: Page 9 of 19 Comments Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) 31. History of Heat Stroke/Heat Exhaustion 32. Heart disease, Arrhythmia, or Irregular Heartbeat 33. Emphysema 34. Diabetes 35. Asthma 36. Cancer 37. Hepatitis C 38. Tuberculosis 39. OBSERVATION ONLY – DO NOT ASK: Surveyor, do you observe signs or symptoms of a serious health condition? 40. Do you have a chronic health condition? A Chronic Health Condition is defined as a diagnosed condition that is more than 3 months in duration and is either not curable or has residual effects that limit daily living and require adaptation in function or special assistance. Examples of chronic health conditions include, but are not limited to: heart disease (including coronary heart disease, angina, heart attack and any other kind of heart condition or disease); severe asthma; diabetes; arthritis-related conditions (including arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia); adult onset cognitive impairments (including traumatic brain injury, post-traumatic distress syndrome, dementia, and other cognitive related conditions); severe headache/migraine; cancer; chronic bronchitis; liver condition; stroke; or emphysema. No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes** Client Name / HMIS ID: _____________________ Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Data not Collected If question #40 was answered as “Yes” (**), then the following questions are required: 40a. Do you expect this condition to be of long–continued No Client Doesn’t Know and indefinite duration AND substantially impair your ability Yes Client Refused to live independently? Data not Collected 40b. Do you have documentation of the disability and No severity on file? Yes 40c. Are you currently receiving services or treatment for No Client Doesn’t Know this condition? Yes Client Refused Data not Collected 41. Do you have a physical disability? Client Doesn’t Know No Client Refused Yes** Data not Collected If question #41 was answered as “Yes” (**), then the following questions are required: 41a. Do you expect this condition to be of long–continued Client Doesn’t Know and indefinite duration AND substantially impair your ability No Client Refused Yes to live independently? Data not Collected 41b. Do you have documentation of the disability and No severity on file? Yes 41c. Are you currently receiving services or treatment for Client Doesn’t Know No this condition? Client Refused Yes Data not Collected Version 1.1 Survey Part 1: Page 10 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ 42. Do you have a need for a housing unit with specific features that No Client Doesn’t Know make it accessible to people with mobility or sensory disabilities? Yes** Client Refused 42a. If accommodations are necessary, Accessible entrance Accessible kitchens and which features are required? bathrooms Elevator or ground floor unit Rails in bathrooms Wheelchair accessibility 43. Have you ever had problematic drug or alcohol use, abused No Client Doesn’t Know drugs or alcohol, or told you do? Yes Client Refused 44. Do you currently have a drug or alcohol problem? No Client Doesn’t Know Alcohol* Client Refused Drug* Data not Collected Both* If question #44 was answered as “Alcohol”, “Drug”, or “Both” (**), then the following questions are required: 44a. Do you expect this condition to be of long–continued Client Doesn’t Know and indefinite duration AND substantially impair your ability No Client Refused Yes to live independently? Data not Collected 44b. Do you have documentation of the disability and No severity on file? Yes 44c. Are you currently receiving services or treatment for Client Doesn’t Know No this condition? Client Refused Yes Data not Collected 45. Have you consumed alcohol and/or drugs almost every day or No Client Doesn’t Know every day for the past month? Yes Client Refused 46. Have you ever used injection drugs or shots in the last six No Client Doesn’t Know months? Yes Client Refused 47. Have you ever been treated for drug or alcohol problems and No Client Doesn’t Know returned to drinking or using drugs? Yes Client Refused 48. Have you used non-beverage alcohol like cough syrup, No Client Doesn’t Know mouthwash, rubbing alcohol, cooking wine, or anything like that in Yes Client Refused the past six months? 49. Have you blacked out because of your alcohol or drug use in the No Client Doesn’t Know past month? Yes Client Refused OBSERVATION ONLY – DO NOT ASK: No 50. Surveyor, do you observe signs or symptoms or problematic Yes alcohol or drug abuse? 51. Have you ever been taken to a hospital against your will for a No Client Doesn’t Know mental health reason? Yes Client Refused 52. Have you gone to the emergency room because you weren’t No Client Doesn’t Know feeling 100% well emotionally or because of your nerves? Yes Client Refused 53. Have you spoken with a psychiatrist, psychologist or other mental health professional in the last six months because of your No Client Doesn’t Know mental health – whether that was voluntary or because someone Yes Client Refused insisted that you do so? No Client Doesn’t Know 54. Have you had a serious brain injury or head trauma? Yes Client Refused 55. Have you ever been told you have a learning disability or Client Doesn’t Know No developmental disability? Client Refused Yes** Data not Collected If question #55 was answered as “Yes” (**), then the following questions are required: Version 1.1 Survey Part 1: Page 11 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) 55a. Do you expect this to be of long–continued and indefinite duration AND substantially impair your ability to live independently? 55b. Do you have documentation of the disability and severity on file? 55c. Are you currently receiving services or treatment for this condition? 56. Do you have any problems concentrating and/or remembering things? 57. OBSERVATION ONLY – DO NOT ASK: Surveyor, do you detect signs or symptoms of severe, persistent mental illness or severely compromised cognitive functioning? 58. Do you feel you currently have a mental health problem? No Yes Client Name / HMIS ID: _____________________ Client Doesn’t Know Client Refused Data not Collected No Yes No Yes No Yes Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused No Yes Client Doesn’t Know Client Refused Data not Collected If question #58 was answered as “Yes” (**), then the following questions are required: 58a. Do you expect this condition to be of long–continued Client Doesn’t Know and indefinite duration AND substantially impair your ability No Client Refused Yes to live independently? Data not Collected 58b. Do you have documentation of the disability and No severity on file? Yes 58c. Are you currently receiving services or treatment for Client Doesn’t Know No this condition? Client Refused Yes Data not Collected 59. Have you had any medicines prescribed to you by a doctor that No Client Doesn’t Know you do not take, sell, had stolen, misplaced, or where the Yes Client Refused prescriptions were never filled? 60. Yes or No (no explanation necessary) – Have you experienced any emotional, physical, psychological, sexual or other type of No Client Doesn’t Know abuse or trauma in your life which you have not sought help for, Yes Client Refused and/or which has caused your homelessness? 61. Have you been a victim of domestic violence or a victim of No Client Doesn’t Know intimate partner violence? Yes** Client Refused Data not Collected If question #61 was answered as “Yes” (**), then the following question is required: 61a. If you experienced domestic or intimate partner Within the past three months violence, how long ago did you have this experience? Three to six months ago (excluding six months exactly) From six to twelve months ago (excluding one year exactly) More than a year ago Client Doesn’t Know Client Refused Data not Collected Version 1.1 No Yes** Survey Part 1: Page 12 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ SCRIPT: Thanks so much for everything you’ve shared with me so far. Now I have some follow-up questions based on your earlier answers. NOTE TO SURVEYOR: Each of the following questions are applicable for certain subpopulations, only read the questions that are applicable to your respondent. ADULTS (18+) OR HEAD OF HOUSEHOLDS: For adults18 and older or Head of Household < 18 years old, req’d questions shaded Question 62. Are you currently employed? Check One Answer No* Client Doesn’t Know Yes** Client Refused If question #62 was answered as “No” (*), then the following question is required: 62a. Are you…. Looking for work (read options to the right) Unable to work Not looking for work If question #62 was answered as “Yes” (**), then the following question is required: 62b. What type of employment do Full-time you have? Part-time Seasonal / sporadic (including day labor) Comments ADULTS (18+) w/ NO INCOME - Adults aged 18 and older having NO financial resources only (question on PAGE 3) Question 63. If you do not have an income, and are unable to receive general relief, what’s the reason why? Check One Answer Sanctioned Time Limits Employment Comments Other N/A WOMEN (15+) - Women aged 15 and older only (Age on PAGE 1) Question 64. Are you pregnant? Check One Answer No Client Doesn’t Know Yes* Client Refused N/A If question #64 was answered as “Yes” (*), then the following question is required: 64a. What is your due date? ____/____/_______ Comments YOUTH (17 and under) - Head of Households aged 17 and under only (Age on PAGE 1) Question 65. Did you run away from home or a foster care home? (Are you a runaway youth?) Check One Answer No Yes Comments Client Doesn’t Know Client Refused N/A TRANSITION AGE YOUTH (TAY) - Head of Households aged 16 to 24 only, required questions are shaded (Age on PAGE 1) Question 66. Are you a current or former foster care youth? 67. Have you ever been in the juvenile justice system? Version 1.1 Check One Answer No Yes No Yes Survey Part 1: Page 13 of 19 Comments Client Doesn’t Know Client Refused Client Doesn’t Know Client Refused Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) 68. Have you ever been on adult probation? 69. Which of the following best represents how you think about yourself? No Yes Straight Lesbian or Gay Bisexual Client Name / HMIS ID: _____________________ Client Doesn’t Know Client Refused Questioning Client Doesn’t Know Client Refused VETERAN - US Veterans only, required questions are shaded (Military Service on PAGE 3) Question 70. Which branch of the military did you serve in? Check One Answer Comments Army Coast Guard Air Force Client Doesn’t Know Navy Client Refused Marines Data not Collected 71. What type of discharge did you receive? Honorable General under honorable conditions Other than honorable conditions (OTH) Bad Conduct Dishonorable Uncharacterized Client Doesn’t Know Client Refused Data not Collected 72. When did you enter military service? ____/____/_________ Doesn’t Know NOTE: The following questions are required for SSVF programs, but HIGHLY recommended to be completed for all veterans. 73. When did you separate from military service? ____/____/_________ Doesn’t Know 74. What is the AMI percentage for the Less than 30% Household's Income? 30% to 50% Greater than 50% 75. How many consecutive months were on you on active duty status? ________ months Doesn’t Know 76. Do you have a service connected disability? No Client Doesn’t Know Yes** Client Refused Data not Collected If question #76 was answered as “Yes” (**), then the following questions are required: 76a. What is the percentage? ________ % Doesn’t Know Did you serve in any of the following wars/war eras? 77. World War II No Dec. 1941 – Dec. 1946 Yes 78. Korean War Jun. 1950 – Jan. 1955 No Yes 79. Vietnam War Feb. 1961 – May 1975 No Yes 80. Persian Gulf War (Operation Desert Storm) Aug. 1990 – April 1991 No Yes Version 1.1 Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected Survey Part 1: Page 14 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) 81. Afghanistan (Operation Enduring Freedom) Oct. 2001 - Present No Yes 82. Iraq (Operation Iraqi Freedom) Mar. 2003 – Aug. 2010 No Yes 83. Iraq (Operation New Dawn) Sept. 2010 – Dec. 2011 No Yes 84. Other Peace-keeping Operations or Military Interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) No Yes Client Name / HMIS ID: _____________________ Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected Client Doesn’t Know Client Refused Data not Collected SCRIPT: In order for us to assist with coordinating your care and to avoid inappropriate referrals, we'd like to ask you a few questions about some services you may have been in contact with and a couple back-ground questions. Department of Mental Health (DMH) and Department of Health Services (DHS) – Required questions are shaded Question 85. What clinic(s) or program(s) have you received mental health services at? 86. Are you enrolled in a DMH or DMH contracted program? DMH stands for the LA County Department of Mental Health. *If yes, please administer DMH authorization form. Check One Answer ______________________ No Yes** Comments Client Doesn’t Know Client Refused NOTE: If your respondent answers “No,” but you know the answer in #85 to be a DMH operated or contracted program, please check “yes” and proceed to #86a. If question #86 was answered as “Yes” (**) and/or if question #85 was answered as a DMH operated or contracted program, then the following questions are required: 86a. When was your last visit? Within the past 6 months Client Doesn’t Know Longer than 6 months Client Refused 86b. When was the last date that you received mental health services? ____/_____/_____ 86c. To which clinic(s) have you gone? ______________ 86d. Who is your primary point of contact there? _________________________________________ 87. Have you been a patient at any of the Do not go for care Health Centers following DHS hospitals or at a DHS Antelope Valley Health Health Center in the past 12 months? Center Hospitals DHS stands for the LA County Bellflower Health Center LAC + USC Med Center Department of Health Services. If other, Dollarhide Health Center Harbor UCLA Med Center please state the name of the specific DHS Olive View Med Center Glendale Health Center Health Center. La Puente Health Center Rancho Los Amigos *check all that apply* Lake Los Angeles Health Center Multi-Service Ambulatory Care NOTE: If the respondent lists private Centers Little Rock Health Center hospitals that are not part of the County Martin Luther King, Jr. San Fernando Health health system, please note than in Outpatient Center Center questions 26/26a High Desert Regional Health South Antelope Valley Center Health Center Wilmington Health Continued on Next Page Center Version 1.1 Survey Part 1: Page 15 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Other Other DHS clinic (Specify in Comment) Comprehensive Health Centers El Monte Comprehensive Health Center Edward R. Roybal Comprehensive Health Center H. Claude Hudson Comprehensive Health Center Hubert H. Humphrey Comprehensive Health Center Long Beach Comprehensive Health Center Mid-Valley Comprehensive Health Center If any hospital or center was answered for question #87, then the following question is required: 5 87a. How many times have you 1 6 accessed services at the DHS site(s) in 2 7 the last 12 months? 3 *If 2 or more, please administer DHS pre More than 7 4 screen form. Client doesn’t know ADDITIONAL BACKGROUND QUESTIONS - All clients, required questions are shaded Question 88. Would you be interested in housing options such as shared housing, a room for rent, or sober living? 89. Are you required to register as a sex offender? 90. Have you ever been convicted of manufacturing or producing methamphetamine? Check One Answer No Client Doesn’t Know Yes Client Refused No Client Doesn’t Know Yes Client Refused No Client Doesn’t Know Yes Client Refused Comments PHOTO - All clients, required questions are shaded Question 91. To finish up this section of the survey, may I take your picture so that we can better find you if housing turns up? If they refuse a live picture, ask if you can take a picture with them or of a photo ID. Check One Answer Yes No WRAP-UP INFORMATION – Required questions are shaded Interviewer’s Information First Name Last Name Email Phone # Org. Version 1.1 Housing Navigator’s Information Same as Interviewer Not Yet Assigned First Name Last Name Email Phone # Org. Survey Part 1: Page 16 of 19 Additional Social Service or Case Manager Contact (Do you already work with a case manager or outreach worker that you trust?) First Name Last Name Email Phone # Org. Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) Client Name / HMIS ID: _____________________ Survey Information Referring Agency (If Applicable) N/A When was this survey conducted? ________ / ________ / _________ Time: ____________ AM/PM (Date and Time) Location of Survey (*Please update later if respondent is later attached to Housing Navigator in a different Region) SPA Region City / Community Lancaster Lancaster SPA 1 - Antelope Valley Palmdale Palmdale Other Santa Clarita Castaic Saugus Valencia Newhall Val Verde North Canyon Country San Fernando Granada Hills Sand Canyon Sylmar SPA 2 - San Fernando Valley Woodland Hills Porter Ranch Winnetka Canoga Park Calabasas West Hills West Agoura Hills Westlake Village Chatsworth Hidden Hills Reseda Tarzana Warner Center Van Nuys Panorama City Lake Balboa Studio City Central Valley Glen Valley Village Sherman Oaks Northridge Encino North Hills North Hollywood Arleta Sunland Lakeview Terrace SPA 2 - San Fernando Valley East Tujunga Mission Hills Pacoima Granada Hills Shadow Hills Sun Valley Burbank Glendale Universal City Flintridge Glendale La Crescenta Toluca Lake La Canada Pasadena Monrovia Altadena Arcadia San Marino San Gabriel West South Pasadena Monterey Park Alhambra Duarte Sierra Madre Bradbury Hermon SPA 3 – San Gabriel Valley El Monte West Covina South El Monte La Puente Irwindale Rosemead Central Baldwin Park Temple City Azusa Hacienda Heights Covina Glendora Version 1.1 Survey Part 1: Page 17 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) East Downtown Hollywood North East LA SPA 4 – Metro/Central LA Silverlake/Westlake Central Mid-Wilshire SPA 5 - West LA West LA South SPA 6 - South LA North South East West SPA 7 - Southeast / East LA Version 1.1 LCA 1: Central Client Name / HMIS ID: _____________________ San Dimas Diamond Bar La Verne Walnut Claremont Industry Pomona Downtown Hollywood Hollywood Hills E. Ho/ Los Feliz West Hollywood Eagle Rock Mount Olympus El Sereno Highland Park Glassell Park Monterey Hills Cypress Park Atwater Village Montecito Heights Mount Washington Chinatown Boyle Heights East LA Silverlake Echo Park Westlake Pico Union Korea Town Park La Brea Mid-City Hancock Park West Mid-City Larchmont District Miracle Mile Wilshire Bel Air Santa Monica Beverly Hills Venice Beverly Crest Westchester Beverly Glen Westwood Brentwood Culver City Holmby Hills Palms Pacific Palisades Rancho Park Malibu South Robertson Marina Del Rey Laurel Canyon Manchester Mar Vista Compton Rosewood Florence Willowbrook South Central Watts South Los Angeles Crenshaw West Adams Jefferson Park Baldwin Hills University Park Leimert Park Ladera Heights Vermont West Adams Lynwood Paramount Hyde Park Windsor Hills Bell Maywood Bell Gardens South Gate Commerce Vernon Cudahy County Unincorporated Huntington Park Survey Part 1: Page 18 of 19 Modified 3/19/2015 CES Survey: Part 1 (VI-SPDAT & Intake) La Mirada Montebello Pico Rivera Artesia Bellflower Cerritos Hawaiian Gardens Lakewood Harbor City Harbor Gateway Inglewood Long Beach Hermosa Beach Manhattan Beach LCA 2: North LCA 3: South LCA 4: Long Beach Harbor Area SPA 8 - South Bay Client Name / HMIS ID: _____________________ North Long Beach Beach Cities Question SURVEYOR ONLY – DO NOT ASK: Is the respondent chronically homeless? Santa Fe Springs Whittier County Unincorporated Downey Norwalk County Unincorporated Signal Hill County Unincorporated San Pedro Wilmington Torrance Redondo Beach Check One Answer No Yes Comments To be chronically homeless, the client must be an unaccompanied homeless individual (or adult in a family) with a disabling condition who has been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three years. To be considered chronically homeless, a person must have been sleeping in a place not meant for human habitation (e.g., living on the streets) and/or in an emergency shelter during that time. OFFICE USE ONLY: Has the client been officially certified for any of the following? DHS – Housing for Health SSVF VASH DMH – Housing Voucher MHSA Certification Is the client already receiving supportive services that can/will follow him/her into permanent housing? Yes No If yes, what agency provides those supportive services? ______________________________________________________ Contact Information for supportive services attachment OFFICE USE ONLY: ADDITIONAL SURVEYOR OSBSERVATIONS May include observations about client or location, such as description of make-shift shelter, detailed description of vehicle (if respondent was residing in vehicle) I Version 1.1 Survey Part 1: Page 19 of 19 Modified 3/19/2015 CES Survey: Part 2 (Housing Preferences) Client Name / HMIS ID: _________________ Part 2 of the CES Survey is MUCH shorter - I’m going to ask you some questions about housing. Just to be clear, this is not a housing application. These are just questions to get a better idea of what kind of housing might be right for you. RESIDENCY & PREFERENCES 1. What city within the County of Los Angeles do you live in? Agoura Hills Downey Alhambra Duarte Arcadia El Monte Artesia El Segundo Avalon Gardena Azusa Glendale Baldwin Park Glendora Bell Hawaiian Gardens Bell Gardens Hawthorne Bellflower Hermosa Beach Beverly Hills Hidden Hills Bradbury Huntington Park Burbank Industry Calabasas Inglewood Carson Irwindale Cerritos La Cañada Flintridge Claremont La Habra Heights Commerce La Mirada Compton La Puente Covina La Verne Cudahy Lakewood Culver City Lancaster Diamond Bar Lawndale Lomita Long Beach Los Angeles If checked, proceed to 1a Lynwood Malibu Manhattan Beach Maywood Monrovia Montebello Monterey Park Norwalk Palmdale Palos Verdes Estates Paramount Pasadena Pico Rivera Pomona Rancho Palos Verdes Redondo Beach Rolling Hills Rolling Hills Estates Rosemead 1a. If you reside within the City of Los Angeles, in which community do you live in? Atwater Village Harbor City Mid Wilshire Baldwin Hills Harbor Gateway Miracle Mile Bel Air Hermon Montecito Heights Beverly Crest Highland Park Mount Washington Beverly Glen Hollywood North Hollywood Boyle Heights Holmby Hills Northridge Brentwood Hyde Park Pacific Palisades Canoga Park Jefferson Park Pacoima Century City Korea Town Palms Chatsworth Ladera Heights Panorama City Chinatown Lake Balboa Porter Ranch Cypress Park Lake View Terrace Rancho Park Downtown Los Angeles Larchmont District Reseda (Skid Row) Laurel Canyon San Pedro Eagle Rock Leimert Park Shadow Hills East Hollywood Lincoln Heights Sherman Oaks Echo Park Los Feliz Silver Lake Encino Manchester South Central Granada Hills Mar Vista South Los Angeles Glassel Park Marina Del Ray South Robertson Hancock Park Mid City Southeast Los Angeles Version 1.1 Survey Part 2: Page 1 of 5 San Dimas San Fernando San Gabriel San Marino Santa Clarita Santa Fe Springs Santa Monica Sierra Madre Signal Hill South El Monte South Gate South Pasadena Temple City Torrance Vernon Walnut West Covina West Hollywood Westlake Village Whittier Studio City Sun Valley Sunland Sylmar Tarzana Toluca Lake Tujunga University Park Van Nuys Venice Vermont Warner Center Watts West Adams West Hills Westlake Westwood Wilmington Wilshire Winnetka Woodland Hills Modified 3/19/2015 CES Survey: Part 2 (Housing Preferences) 2. How many months have you stayed in that city/community? (Location checked in Q1/1a) 3. What other cities have you called home within the last year (last 12 months)? *SURVEYOR NOTE: Write the city or cities –separated by row - from the table above in question 1 4. Is this region - where I’m surveying you right now - where you’re looking to be housed? *SURVEYOR NOTE: location may be different from answer to Q1/1a 4a. If no, what is the community you are looking to be housed in? *SURVEYOR NOTE: Please check ONLY ONE SPA. Client Name / HMIS ID: _________________ ____________ months ___________________________________ ___________________________________ ___________________________________ Yes Yes (anywhere is fine) No, I have another community in mind proceed to 4a SPA 1 – Antelope Valley SPA 2 – San Fernando Valley SPA 3 – San Gabriel Valley SPA 4 – Metro/Central LA SPA 5 – West LA SPA 6 – South LA SPA 7 – Southeast / East LA SPA 8 – South Bay 5. What community, if any, will you not accept offers for housing in? ________________________________________ QUESTIONS TO ASSIST WITH HOUSING MATCH 6. If you were able to locate housing, do you have money saved up for move-in or housing? 7. How many adults will this unit need to accommodate including yourself? 8. Have you ever been evicted from housing or abandoned a unit, of which your name was on the lease? 8a. If yes, approximate month and year of last eviction: If you are unsure of the day, please select the first day of the month. 9. Were any of the evictions from Public Housing Authority units? 9a. If you’ve been evicted from a PHA unit, was it due to fraud? 9a1. If yes, approximate month and year of the last eviction due to fraud: If you are unsure of the day, please select the first day of the month. 9b. If you’ve been evicted from a PHA unit, was it due to unit damage? 9b1. If applicable, approximate month and year of the last eviction due to unit damage: If you are unsure of the day, please select the first day of the month. 9c. If you’ve been evicted from a PHA unit, do you owe money? 9c1. If yes, do you have a payment plan in place? 10. Have you ever been convicted of a felony? 10a. If yes, please describe all felonies for which you have been convicted? 10b. If yes, when was the month and year of your last conviction? If you are unsure of the day, please select the first day of the month. 10c. If you’ve been convicted, were any of the felonies considered violent? 10d. If yes, when was the month and year of your last violent felony conviction? If you are unsure of the day, please select the first day of the month. 11. Have you ever been convicted of arson? Version 1.1 Survey Part 2: Page 2 of 5 Yes No Refused Unsure 1 2 3 4 5 6 7 8 or more Yes No Refused Unsure ______ / ______ / ___________ Yes No Refused Unsure Yes No Refused Unsure ______ / ______ / ___________ Yes No Refused Unsure ______ / ______ / ___________ Yes No Refused Unsure Yes No Refused Unsure Yes No Refused Unsure ______ / ______ / ___________ Yes No Refused Unsure ______ / ______ / ___________ Yes No Refused Unsure Modified 3/19/2015 CES Survey: Part 2 (Housing Preferences) 12. Have you been in jail or prison in the last 6 months? 13. Are you currently on probation or parole? 14. Do you need a smoking or non-smoking apartment? 15. Do you have a pet? Client Name / HMIS ID: _________________ Yes No Refused Unsure Yes No Refused Unsure Smoking Non-smoking No preference Yes No Refused Unsure 15a. If yes, is it a certified service animal or emotional support animal? 16. Are there other requirements or requests around permanent housing that we need to be aware of? **check all that apply; read question as open ended question, and allow respondent to respond; do not voluntarily suggest the answers listed to the right** Version 1.1 Survey Part 2: Page 3 of 5 Yes No Refused Unsure 1st Floor Elevator Upper Floor Private Bathroom Kitchenette Public Transit Other: Modified 3/19/2015 CES Survey: Contact Sheet Thank you for completing this survey. Your answers will help us better understand your health and housing needs and the needs of our community, and may help us make better referrals for you in the future. For more information about the Coordinated Entry System or this survey, please contact: SPA __ Community Coordinator: ____________________________________________ Phone: ________________________________________________________________ Email: _________________________________________________________________ Address of regional access center: __________________________________________ ______________________________________________________________________ Follow up contact (if applicable): Outreach Worker/Housing Navigator: ________________________________________ Phone: ________________________________________________________________ Email: _________________________________________________________________ Version 1.1 Modified 3/19/2015
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