RHY MGH TLP Supplemental Service Referral - nh

New Hampshire Continua of Care
RHY MGH/TLP Supplemental Services and Referrals HMIS Form
Use this form to record services and referrals information. Record services for the youth to whom they were
provided; a service that benefits the whole household in TLP or MGH may be recorded solely for the youth head of
household. For each service provided, projects must record the service date and service type. Use additional forms as
needed for multiple services and/or referrals. Update the information as required each time services and/or referrals
are provided.
Client name or other identifier: _________________________________ Client ID*: _________________________
*Client ID number is generated by the HMIS system.
Referrals Provided
In ServicePoint, click to select the Service Transaction tab.
Referral
Referral Date
Child Care Non-TANF
______/______/_________
Supplemental Nutritional Assistance Program (Food Stamps)
______/______/_________
Education-McKinney/Vento Liaison Assistance to Remain in School
______/______/_________
HUD Section 8 or Other Permanent Housing Assistance
______/______/_________
Individual Development Account
______/______/_________
Medicaid
______/______/_________
Mentoring Program Other Than RHY Agency
______/______/_________
National Service (AmeriCorp, VISTA, Learn and Serve)
______/______/_________
Non-Residential Substance Abuse or Mental Health Program
______/______/_________
Other Public-Federal, State or Local Program
______/______/_________
Private Non-profit Charity or Foundation Support
______/______/_________
SCHIP
______/______/_________
SSI, SSDI or other Disability Insurance
______/______/_________
TANF or other Welfare/Non-disability Income Maintenance (all
TANF) services
______/______/_________
Unemployment Insurance
______/______/_________
WIC
______/______/_________
Workforce Development (WIA)
______/______/_________
This form can be found on the NH-HMIS website at www.nh-hmis.org.
04/14/2015
RHY MGH/TLP Supplemental Contact Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 1 of 2
New Hampshire Continua of Care
RHY MGH/TLP Supplemental Services and Referrals HMIS Form
Services Provided
In ServicePoint, click to select the Service Transaction tab.
Service
Service Date
Basic Support Services
______/______/_________
Community Service/Service Learning (CSL)
______/______/_________
Counseling/Therapy
______/______/_________
Dental Care
______/______/_________
Education
______/______/_________
Employment and training services
______/______/_________
Criminal justice/legal services
______/______/_________
Life skills training
______/______/_________
Parenting education for parent of youth
______/______/_________
Parenting education for parent of youth with
children
______/______/_________
Peer (youth) counseling
______/______/_________
Post-natal care
______/______/_________
Pre-natal care
______/______/_________
Health/medical care
______/______/_________
Psychological or psychiatric care
______/______/_________
Recreational activities
______/______/_________
Substance abuse assessment and/or treatment
______/______/_________
Substance abuse prevention
______/______/_________
Support group
______/______/_________
04/14/2015
RHY MGH/TLP Supplemental Contact Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 2 of 2