INTAKE FORM HMIS606_004
HMIS606_004 INTAKE FORM Interview Date: _____ / _____ / _____ SS#:________________ Last Name: _______________________ First Name: _________________________ MI: ____ DOB: ____/____/_________ Referred by: Self Street Outreach Worker Emergency/Transitional housing staff Psych. Hospital Staff Other Hospital/Medical Staff Mental Health Outpatient Clinic Sex: Alcohol or Other Drug Program Other Social Service Staff Police/Parole Officer Church Staff Unknown Family/Friend Mental Health Provider Race: Black/African American Caucasian Native Hawaiian/Pacific Islander Asian American Indian/Alaskan Native Other Multi Racial American Indian/Alaskan Native & White Asian & White Black/African American & White Don’t know Refused to answer Marital Status: Single Married Separated Widowed Divorced Gay Male Couple Lesbian Couple Not Specified Male Female Transgender Male to Female Transgender Female to Male Other Don’t know Refused to answer What is your level of education? 0 to 8th grade 9th to 12th grade (non HS grad) HS graduate/GED 12th grade + some college Junior College College graduate Vocational/Technical Graduate degree Veteran Status: Served active duty in United States Armed Forces Served in active duty in military reserves of the National Guard Never served in the military Don’t know Refused to answer Ethnicity: Hispanic/Latino Non-Hispanic/Latino Don’t know Refused Address of where you lived most recently. Note: a zip code must be included. Street Address: ____________________________________________________________________________________ City: ____________________________________ State: _______ Zip: ___________ Phone #______________________ ROSIE Intake Form Page 1 of 8 HMIS606_004 Address of your last permanent location (lived in for 90 days or more) Note: a zip code must be included. Street Address: ___________________________________________________________________________________ City: ____________________________________ State: _______ Zip: ___________ Phone #______________________ Income: Have you received income from any source in the past 30 days? Yes No Don’t know Refused to answer Please mark the source of income and indicate the amount: Food Stamps Part-time Employment Full-time Employment Part-time Employment Spouse Full-time Employment Spouse Supplemental Security Income Supplemental Security Income (SSI for your child) Social Security Disability Income (SSDI) Supplemental Security Income Spouse Supplemental Security Assistance Temporary Rental Assistance State Children’s Health Insurance Temporary Assistance for Needy Families (TANF) TANF Child Care Services TANF Transportation Services Unemployment Insurance Veteran’s Disability Insurance VA Health Care VA Disability Compensation Veteran’s Pension Private Disability Insurance Worker’s Compensation General Assistance (GA) Temporary Cash Assistance (TCA) Rental Assistance Other Non Cash Benefits Other TANF Funded Services Medicare Medicaid WIC Nutritional Program Vocational Rehabilitation Retirement income from Social Security Pension from former job Child Support Alimony or other spousal support Other Source $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ $: ___________ ROSIE Intake Form Page 2 of 8 Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Hour Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Month Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual HMIS606_004 Stats/Shelter: Family Size:_____ # Needing Shelter: ______ Are you Pregnant? Insurance Type: Medicaid Medicare Medical Assistance V A Medical Private None Yes No Months Pregnant: _____ Family Type: Single Female Single Male Female with Children Male with Children Couple with Children Couple without Children Couple with Children Extended Family What is your primary reason for emergency? (Choose one) Stranded/transient Relocating Loss of income Fire Building sold/redeveloped Police condemned Spousal desertion No power Never independent Eviction Mental health problems Section 8 violation Drug/alcohol problems High risk neighborhood Marriage/separation Victim of crime Employment situation Shelter termination 2005 disaster victim Jail/Prison release Other_____________________________ Physical abuse Kicked out of housing/fighting Substandard housing No water Displaced Insufficient income Mental/emotional abuse Institutional discharge Disaster Domestic Violence Where did you stay the night prior to program intake? Emergency Shelter, including hotel or motel paid for with emergency shelter voucher Transitional housing for homeless persons (including homeless youth) Permanent housing for formerly homeless persons (such as SHP, SC, or SRP Mod Rehab) Psychiatric hospital or psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric) Jail, prison, or juvenile detention facility Staying or living in a family member’s room, apartment, or house Staying or living with family, permanent Domestic violence situation In shelter Place to place Shelter transfer to transitional housing Recovery community Hotel or Motel paid for without emergency shelter voucher Foster care home or foster care group home Place not meant for habitation (e.g. vehicle, abandoned building, bus/train/subway station/airport, anywhere outside) Other Safe Haven ROSIE Intake Form Page 3 of 8 HMIS606_004 Rental by client, with VASH housing subsidy (Veterans) Rental by client, with ongoing housing subsidy Owned by client, with ongoing housing subsidy Rental by client, no ongoing housing subsidy Owned by client, no ongoing housing subsidy Don’t know Refused to answer For how long? One week or less More than one week, but less than one month One to three months Four to six months Seven to twelve months One to two years Two to four years Four years and over Don’t know Refused to answer Housing Status: Literally Homeless Housed and at imminent risk of losing housing Housed and at-risk of losing housing Stably housed Don’t know Refused to answer Determination of Chronic Homelessness: Are you an unaccompanied individual who is homeless? Yes No Do you have a disabling condition? Yes No Have you been continuously homeless for a year or more? Yes No Have you had at least four episodes of homelessness in the past three years? Yes No Have you been staying in the area for 30 days prior? Yes No Referred to Shelter? Yes No Name of Shelter: _____________________________________________________ If no referrals explain: __________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ROSIE Intake Form Page 4 of 8 HMIS606_004 Health Do you have any of the following? Health Condition Is condition disabling? Mental Health Issues* Drug Issues* Alcohol Issues* Drug and Alcohol Issues* Substance Abuse Issues* Chronic Health Condition* Developmental Disability* Physical Disability* HIV/AIDS* Victim of Domestic Violence* Chronically Mentally Ill Special Needs Unspecified Disability Communicable Illness MR/DD Issues* Tuberculosis Learning Disability Lupus Attention Deficit Disorder Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK Is client receiving services? Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK DK Medication? Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Refused Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N Completed? Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N If the client is a victim of domestic violence, when did the domestic violence occur? 0 to 3 months ago Over 12 months ago 3 to 6 months ago Don’t know 6 to 12 months ago Refused to answer Do you have any other health issues? Yes No If yes, please explain: __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ ROSIE Intake Form Page 5 of 8 HMIS606_004 Emergency Contacts Relationship: __________________ Last Name: _____________________ First Name: _______________ MI: ______ Street Address: ____________________________________________________________________________________ City: __________________________ State: ____________ Zip: _________ Phone #: __________________________ Relationship: __________________ Last Name: _____________________ First Name: _______________ MI: ______ Street Address: ____________________________________________________________________________________ City: __________________________ State: ____________ Zip: _________ Phone #: __________________________ Comments: ________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ ROSIE Intake Form Page 6 of 8 HMIS606_004 Additional Family Member Information Last Name:____________________________ First Name: _______________________________ MI: ______________ Relationship: ___________________ DOB: ______ /______ /______ SS#: _____ /_____ /______ Sex: Male Female Transgender Male to Female Transgender Female to Male Other Don’t know Refused to answer Ethnicity: Hispanic/Latino Non-Hispanic/Latino Don’t know Refused to answer Race: Black/African American Caucasian Native Hawaiian/Pacific Islander Asian American Indian/Alaskan Native Other Multi Racial American Indian/Alaskan Native & White Asian & White Black/African American & White Don’t know Refused to answer Education: 0 to 8th grade 9th to 12th grade (non HS grad) HS graduate/GED 12th grade + some college Does the family member have a health condition? Yes Graduate degree Junior College College graduate Vocational/Technical No If yes, please fill out the health page of the Intake form for that particular individual. If the client is a victim of domestic violence, when did the domestic violence occur? 0 to 3 months ago Over 12 months ago 3 to 6 months ago Don’t know 6 to 12 months ago Refused to answer Does the family member have any other health issues? Yes No If yes, please explain: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Is the family member Pregnant? Yes No Is the family member a Veteran? Yes No Months Pregnant: __________ Does the Head of Household have legal custody of all minor children? ? Yes No Living Situation Prior to Program Entry (Complete only if different from Head of Household) Living Situation: ____________________________________ Length of Stay: __________________________________ ROSIE Intake Form Page 7 of 8 HMIS606_004 Veteran Information Supplementary Intake Family Member:_________________________________ Vet Status: Yes-Non Combat Yes-In Combat Yes-Combat, Zone Unknown Don’t Know Refused to answer Military Branch: Army Air Force Navy Marines Other Don’t Know Refused Discharge Status: Honorable General Medical Bad Conduct Dishonorable Other Don’t Know Refused to Answer Number of Active Duty Months:_________ Military Era: Persian gulf Era (Aug. 1991-Sept. 10, 2001) Post Vietnam (May 1975-Jul. 1991) Vietnam Era (Aug.1964-Apr. 1975) Between Korean & Vietnam War (Feb. 1955-Jul. 1964) Korean War (Jun. 1950-Jan.1955) Between WWII and Korean War (Aug. 1947-May 1950) World War II (Sept. 1940-Jul. 1947) Post Sept. 11, 2001 (Sept.11, 2001-Present) Don’t Know Refused War Zone Months in War Zone:_________ Afghanistan China, Burma, India Europe Korea Laos and Cambodia North Africa Persian Gulf South China Sea South Pacific Vietnam Other Don’t Know Refused to Answer If in a War Zone, received hostile or friend fire: No Yes Don’t Know Refused ROSIE Intake Form Page 8 of 8
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