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Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Identification (All fields required unless otherwise noted)HMIS consent?No (refused)Signed Consent FormFirst Name:Middle Name (Optional):Last Name:Suffix (Optional):Name Data Quality:Did the client provide their fullname?Full Name ReportedPartial, street name, or codename reportedClient Doesn’t KnowClient RefusedData not CollectedDate of Birth: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://Full DOB reportedApproximate or partial DOBreportedClient Doesn’t KnowClient RefusedData not CollectedFull SSN reportedApproximate or partial SSNreportedClient Doesn’t KnowClient RefusedData not CollectedState:Zip:AddressDataQuality:Full address reportedIncomplete or estimatedaddress reportedClient Doesn’t KnowClient RefusedData not CollectedContact Information (Optional)Phone NumberMain: ( )Alternate: (Email)-xLeave message-xLeave message@Phone nterContact PreferencePhoneAlternate PhoneTextEmailNotesDemographics (All fields required unless otherwise noted)Housing Status:Category 1 - HomelessCategory 2 – At Imminent Risk of Losing Housing (within 14 days or less)Category 3 – Homeless only under other Federal StatutesCategory 4 – Fleeing Domestic ViolenceAt Risk of HomelessnessStably HousedRClient Doesn’t KnowClient RefusedData not CollectedFamily Type:UnaccompaniedSingle ParentTwo ParentsAdults No childrenCompliance Date: 10.01.2016 HUD Data Standards Manual11
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Relation (to Head of Household)SelfHead of Household’s ChildHead of Household’s Spouse or PartnerHead of Household’s other Relation MemberOther: Non-relation MemberGender:MaleClient Doesn’t KnowFemaleClient RefusedTransgender Female to MaleData not CollectedTransgender Male to FemaleDoesn’t identify as male, female, or transgenderDisabled?Veteran(Physical, Developmental, Mental Health, (Have you ever served inChronic Health Condition, HIV/AIDS,the U.S. Military?)and/or Substance Use Disorder.)YesYesNoNoClient Doesn’t KnowClient Doesn’t KnowClient RefusedClient RefusedData not CollectedData not CollectedEthnicityRace (check all that apply)Non-HispanicAsianHispanicBlack or African AmericanClient Doesn’t KnowNative Hawaiian or Other Pacific IslanderClient RefusedAmerican Indian or Alaska NativeData not CollectedWhiteEducation Level(What is the highest level of education you’ve completed?)Less than Grade 5Grades 5-6Grades 7-8Grades 9-11Grade 12 / High school DiplomaGEDSchool program does not havegrade levelsSome CollegeAssociates degreeBachelor’s degreeGraduate degreeVocational CertificationClient doesn’t knowClient RefusedData not collectedClient Doesn’t KnowClient RefusedData not CollectedIncome and Insurance (All fields required unless otherwise noted)Income Source(Check all that apply)No financial resourcesEarned Income (employment wages / cash)Unemployment InsuranceSupplemental Security Income (SSI)Social Security Disability Income (SSDI)VA Service-Connected Disability CompensationVA Non-Service-Connected Disability PensionPrivate Disability InsuranceWorkers CompensationTemporary Assistance for Needy Families (CalWORKs)General Assistance (GA) (General Relief (GR))Retirement Income from Social SecurityPension or retirement income from a former jobChild SupportAlimony or other spousal supportOther Source (Specify:)Client Doesn’t KnowClient RefusedRPay IntervalStatedEvery Other Twice AIncome WeeklyMonthly QuarterlyWeekMonth Compliance Date: 10.01.2016 HUD Data Standards Manual22Yearly
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Data not CollectedRCompliance Date: 10.01.2016 HUD Data Standards Manual33
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Income Documentation (Optional):GR FormCalWORKS FormsPay StubUnemployment Insurance FormsUtility AllowanceW-2 FormsChild Support FormsSSDI FormSocial Security FormsWorkmans CompSSI FormsSelf Employment DocsPension Letter/StubUnemployment FormsSelf DeclarationEmployer Printout/LetterVA DocumentationNon-Cash Benefits (Check all that apply):NoneClient Doesn’t KnowFood Stamps (CalFresh)CalWorks Child CareAmount:CalWorks TransportationWICOther CalWorks-Funded ServicesHealth Insurance (Check all that apply):Client Doesn’t KnowNo Health InsuranceMEDICAREMediCalCOBRA Health Ins.Employer Provided Health Ins.OtherComments (Optional):Client RefusedTemporary Rental AssistanceSection 8 or Rental AssistanceOtherClient RefusedState Children’s Health Ins.Private Health Ins.Data not CollectedMedically NeedyAmount:Data not CollectedVA Medical ServicesIndian Health ServicesProgramClient Note (Optional)Client Note:Type:InformationAlertPrivate Customer:YesNoNote Date:/ /Emergency Contact Information (Optional)Contact TypePhone NumberAlternate Contact(Who is the best person to get intouch with you?)( ) xRelationship:First Name:Last Name:Emergency(In case of an emergency, whoshould we alert?)( ) xSame as aboveRelationship:FirstName:Last Name:RPhone TypeHomeCellWorkMessage CenterEmailHomeCellWorkMessage CenterCompliance Date: 10.01.2016 HUD Data Standards Manual44
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Program Entry (All fields required unless otherwise noted)Program Name:Program Entry Date://Case Manager:Living Situation Questions for Street Outreach, Emergency Shelter, or Safe Haven Projects1. Type of ResidenceHOMELESS SITUATIONPlace not meant for human habitationEmergency shelterSafe HavenInterim HousingINSTITUTIONAL SITUATIONFoster care home or foster care group homeHospital or other residential non-psychiatric medical facilityJail, prison or juvenile detention facilityLong-term care facility or nursing homePsychiatric hospital or other psychiatric facilitySubstance abuse treatment facility or detox centerTRANSITIONAL & PERMANENT HOUSING SITUATIONHotel or motel paid for without emergency shelter voucherOwned by client, no ongoing housing subsidyOwned by client, with ongoing housing subsidyPermanent housing for formerly homeless personsRental by client, no ongoing housing subsidyRental by client, with VASH housing subsidyRental by client, with GPD TIP subsidyRental by client, with other (non-VASH) ongoing housing subsidyResidential project or halfway house with no homeless criteriaStaying or living in a family member's room, apartment, or houseStaying or living in a friend’s room, apartment or houseTransitional housing for homeless personsOtherClient Doesn't KnowClient RefusedData not Collected2. Length of Stay in Prior Living SituationOne night or lessTwo to six nightsOne week or more, but less than onemonthOne month or more, but less than 90 days90 days or more, but less than one yearOne year or longerClient Doesn't KnowClient RefusedData not CollectedProceed to Question 5 - RCompliance Date: 10.01.2016 HUD Data Standards Manual55
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]Living Situation Questions for All Project Types excluding Street Outreach, Emergency Shelter, or Safe Haven Projects1. Type of residence3. Length of stay in prior living situationHOMELESS SITUATIONPlace not meant for human habitationEmergency ShelterSafe HavenInterim HousingINSTITUTIONAL SITUATIONFoster care home or foster care group homeHospital or other residential non-psychiatricmedical facilityJail, prison or juvenile detention facilityLong-term care facility or nursing homePsychiatric hospital or other psychiatric facilitySubstance abuse treatment facility or detoxcenterTRANSITIONAL & PERMANENTHOUSING SITUATIONHotel or motel paid for without emergencyshelter voucherOwned by client, no ongoing housing subsidyOwned by client, with ongoing housing subsidyPermanent housing for formerly homelesspersonsRental by client, no ongoing housing subsidyRental by client, with VASH housing subsidyRental by client, with GPD TIP subsidyRental by client, with other (non-VASH)ongoing housing subsidyResidential project or halfway house with nohomeless criteriaStaying or living in a family member’s room,apartment, or houseStaying or living in a friend’s room, apartment,or houseTransitional housing for homeless personsClient Doesn’t KnowClient RefusedRData notCollected2a. Did you stay less than90 days?NoYes2b. Did you stay less than7 nights?NoYesCompliance Date: 10.01.2016 HUD Data Standards Manual66One nightor lessTwo to sixnightsOneweek ormore, butless thanone monthOnemonth ormore, butless than 90days90 days ormore, butless than oneyearOne yearor longerClientDoesn'tKnowClientRefusedData notCollectedOne nightor lessTwo to sixnightsOneweek ormore, butless thanone monthOnemonth ormore, butless than 90days90 days ormore, butless than one
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]yearOne year or longerClient Doesn't KnowClient RefusedData not CollectedProceed toQuestion 5One night or lessTwo to six nightsOne week or more, but less than one monthOne month or more, but less than 90 days90 days or more, but less than one yearOne year or longerClient Doesn't KnowClient RefusedData not CollectedProceed toQuestion 4Proceed toQuestion 8Proceed toQuestion 4Proceed toQuestion 8Compliance Date: 10.01.2016 HUD Data Standards ManualR77
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]4. On the night before your current housing situation, did you stay on the streets, ES, or SH?NoYes5. Approximate date started//6. Number of times the client has been on the streets, in ES, or SH in the past three years including today.Never in three yearsThree timesClient Doesn’t KnowOne timeFour or more timesClient RefusedTwo timesData not Collected7. Total number of months homeless on the streets, in ES, or SH in the past three years.One month (this time is the first month)71228More than 12 months39Client Doesn’t Know410Client Refused511Data not Collected6HOMELESSNESS - Adults aged 18 and older and Head of Household 18 years old, required questions are shadedQuestion8. What city were you residing inimmediately prior to entry into this project?Check One AnswerAliso ViejoAnaheimAtwoodBalboaBreaBuena ParkCapistrano BeachCorona del MarCosta MesaCoto de CazaCypressDana PointEl ModenaFountain ValleyFullertonGarden GroveHuntington BeachIrvineLa HabraLa PalmaLaguna BeachLaguna HillsLaguna NiguelLaguna WoodsLake ForestLas FloresLemon HeightsLos AlamitosMidway CityMission ViejoNewport BeachOrangePlacentiaRancho SantaMargaritaCommentsSan ClementeSan JuanCapistranoSanta AnaSeal BeachStantonSunset BeachTustinVilla ParkWestminsterYorba LindaOutside OrangeCountyClient Doesn’tKnowClient RefusedData not CollectedWELLNESS – All clients, required questions are shadedQuestion9. Have you been diagnosed with AIDS or have you tested positivefor HIV?RCheck One AnswerClient Doesn’t KnowNoClient RefusedYes**Data not CollectedCommentsCompliance Date: 10.01.2016 HUD Data Standards Manual88
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]9a. Do you expect this to substantially impair your ability to liveindependently?(Required if question 9 is ‘Yes’)RNoYesClient Doesn’t KnowClient RefusedData not CollectedCompliance Date: 10.01.2016 HUD Data Standards Manual99
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]9b. Do you have documentation of the disability and severity onfile?(Required if question 9 is ‘Yes’)9c. Are you currently receiving services or treatment for thiscondition?(Required if question 9 is ‘Yes’)10. Do you have a chronic health condition?NoNoYesNoYes**YesClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not Collected10a. Do you expect this to be of long–continued and indefiniteduration AND substantially impair your ability to liveindependently?(Required if question 10 is ‘Yes’)10b. Do you have documentation of the disability and severity onfile?NoYesNoYes10c. Are you currently receiving services or treatment for thiscondition?(Required if question 10 is ‘Yes’)11. Do you have a physical disability?NoYesClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not Collected(Required if question 10 is ‘Yes’)11a. Do you expect this to be of long–continued and indefiniteduration AND substantially impair your ability to liveindependently?(Required if question 11 is ‘Yes’)11b. Do you have documentation of the disability and severity onfile?(Required if question 11 is ‘Yes’)11c. Are you currently receiving services or treatment for thiscondition?(Required if question 11 is ‘Yes’)12. Do you currently have a drug or alcohol problem?12a. Do you expect this to be of long–continued and indefiniteduration AND substantially impair your ability to liveindependently?(Required if question 12 is ‘Alcohol’, ‘Drug’, or ‘Both’)12b. Do you have documentation of the disability and severity onfile?(Required if question 12 is ‘Alcohol’, ‘Drug’, or ‘Both’)12c. Are you currently receiving services or treatment for thiscondition?(Required if question 12 is ‘Alcohol’, ‘Drug’, or ‘Both’)12d. How was the substance abuse condition confirmed?(Required if question 12 is ‘Alcohol’, ‘Drug’, or ‘Both’)RNoYes**Client Doesn’t KnowClient RefusedData not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedNoYesNoYesNoAlcohol**Drug**Both**Client Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedUnconfirmed; presumptive or selfreportConfirmed through assessment andclinical evaluationNoYesCompliance Date: 10.01.2016 HUD Data Standards Manual101
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]13. Have you ever been told you have a learning disability ordevelopmental disability?13a. Do you expect this to be of long–continued and indefiniteduration AND substantially impair your ability to liveindependently?(Required if question 13 is ‘Yes’)13b. Do you have documentation of the disability and severity onfile?(Required if question 13 is ‘Yes’)13c. Are you currently receiving services or treatment for thiscondition?(Required if question 13 is ‘Yes’)14. Do you feel you currently have a mental health problem?14a. Do you expect this to be of long–continued and indefiniteduration AND substantially impair your ability to liveindependently?(Required if question 14 is ‘Yes’)14b. Do you have documentation of the disability and severity onfile?(Required if question 14 is ‘Yes’)14c. Are you currently receiving services or treatment for thiscondition?(Required if question 14 is ‘Yes’)14d. How was the mental health condition confirmed?(Required if question 14 is ‘Yes’)14e. Does the client have a serious mental illness? If so, how wasit confirmed?(Required if question 14 is ‘Yes’)15. Have you been a victim of domestic violence or a victim ofintimate partner violence?RConfirmed by prior evaluation orclinical recordsClient Doesn’t KnowNoClient RefusedYes**Data not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedNoYesNoYesNoYes**Client Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedNoYesClient Doesn’t KnowClient RefusedData not CollectedUnconfirmed; presumptive or selfreportConfirmed through assessment andclinical evaluationConfirmed by prior evaluation orclinical recordsNoUnconfirmed; presumptive or selfreportConfirmed through assessment andclinical evaluationConfirmed by prior evaluation orclinical recordsClient Doesn’t KnowClient RefusedNoClient Doesn’t KnowYesClient RefusedData not CollectedNoYesCompliance Date: 10.01.2016 HUD Data Standards Manual111
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]15a. How long ago did you have this experience?(Required if question 15 is ‘Yes’)RWithin the past three monthsThree to six months ago(excluding six months exactly)From six to twelve months ago(excluding one year exactly)Compliance Date: 10.01.2016 HUD Data Standards Manual121
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]More than a year agoClient Doesn’t KnowClient RefusedData not CollectedNoClient Doesn’t KnowYesClient RefusedData not Collected15b. Are you currently fleeing?(Required if question 15 is ‘Yes’)EMPLOYMENT: For adults18 and older or Head of Household 18 years old, required questions shadedQuestion16. Are you currently employed?16a. Why are you not employed?(Required if question 16 is ‘No’)16b. What type of employment do you have?(Required if question 16 is ‘Yes’)Check One AnswerNoClient Doesn’t KnowYesClient RefusedLooking for workUnable to workNot looking for workFull-timePart-timeSeasonal / sporadic (including day labor)CommentsPREGNANCY - Females who are head of household, 18 and over, or are an unaccompanied youth onlyQuestion17. Are you pregnant?17a. What is your due date?(Required if question 17 is ‘Yes’)Check One AnswerNoClient Doesn’t KnowYesClient RefusedData not Collected//CommentsYOUTH - Head of Households aged 17 and under onlyQuestion18. Did you run away from home or a fostercare home?Check One AnswerNoYesClient Doesn’t KnowClient RefusedCommentsVETERAN - US Veterans only, required questions are shadedQuestion19. Which branch of the military did you serve in?RCheck One AnswerArmyCoast GuardAir ForceClient Doesn’t KnowNavyClient RefusedMarinesData not CollectedCommentsCompliance Date: 10.01.2016 HUD Data Standards Manual131
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]20. What type of discharge did you receive?RHonorableGeneral under honorable conditionsOther than honorable conditions (OTH)Bad ConductDishonorableUncharacterizedClient Doesn’t KnowClient RefusedData not CollectedCompliance Date: 10.01.2016 HUD Data Standards Manual141
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]21. 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.22. When did you separate from military service?/ /Doesn’t Know23. Household Income as a Percentage of AMILess than 30%30% to 50%Greater than 50%24. VAMC Station ScoreDid you serve in any of the following wars/war eras?25. World War IINoDec. 1941 – Dec. 1946Yes26. Korean WarJun. 1950 – Jan. 1955NoYes27. Vietnam WarFeb. 1961 – May 1975NoYes28. Persian Gulf War (Operation Desert Storm)Aug. 1990 – April 1991NoYes29. Afghanistan (Operation Enduring Freedom)Oct. 2001 - PresentNoYes30. Iraq (Operation Iraqi Freedom)Mar. 2003 – Aug. 2010NoYes31. Iraq (Operation New Dawn)Sept. 2010 – Dec. 2011NoYes32. Other Peace-keeping Operations or MilitaryInterventions (such as Lebanon, Panama,Somalia, Bosnia, Kosovo)NoYesClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedClient Doesn’t KnowClient RefusedData not CollectedCHRONIC HOMELESSNESS - Adults aged 18 and older and Head of Household 18 years old, required questions are shadedQuestionASSESSOR ONLY – DO NOT ASK:33. Is the client chronically homeless?Check One AnswerNoYesCommentsTo be chronically homeless, the client must be a homeless individual or a family with an adult head ofhousehold (or if there is no adult in the family, a minor head of household) with a disability who lives in aplace not meant for human habitation, a safe haven, or in an emergency shelter; and has beenhomeless continuously for at least 12 months or on at least 4 separate occasions in the last 3 yearswhere the combined occasions equal at least 12 monthsRCompliance Date: 10.01.2016 HUD Data Standards Manual151
Nashville HMIS Intake [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRYTemplate Use ASSESSMENT TEMPLATE]PATH Questions: Required for PATH-Funded Clients ONLY34. Was the client determined to beeligible for PATH funded services andenrolled in PATH?34a. If not eligible to be enrolled, what isthe reason?(Required if question 34 is ‘No’)35. On what date was the client's eligibilityand/or enrollment determined?36. Is the client connected with SOAR?NoYesClient was found ineligible for PATHClient was not enrolled for other reason(s)NoYes//Client Doesn’t KnowClient RefusedData not CollectedI certify that the information above is correct to the best of my knowledge.Client SignatureSiteDateAgency Staff SignatureSiteDateDO NOT WRITE IN BOX BELOW – DATA ENTRY PERSONNEL ONLY (Optional):Date entered into HMIS://QuestionAnswerWas the hard copy exit form completelyfilled out correctly?YesNoInitials of StaffcompletionCommentsStaff Name (verifying completion of Data Entry):RCompliance Date: 10.01.2016 HUD Data Standards Manual161
Nashville HMIS Intake Template Use [HHS FUNDED: PATH: PROJECTS: HMIS INTAKE AT ENTRY ASSESSMENT TEMPLATE] Compliance Date: 10.01.2016 HUD Data Standards Manual. . Total number of months homeless on the streets, in ES, or SH in the past three years. One month (this time is the first month) 7 12
