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 #______________________
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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
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ROSIE Intake Form Page 2 of 8
Hour
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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
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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: __________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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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:
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
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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: ________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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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: __________________________________
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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
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