HMIS Standard Intake Form for PSH, TH, SSO, and RRH Projects This Form Is NOT to Be Used

HMIS Standard Exit Form for RHY Effective 10/01/2017

Exit Date ServicePoint (HoH) ID: / /

Project Name

Head of Household Name SSN Last four digits

first middle last suffix

If Partial Household Exit (if the whole household is existing, skip to Destination) Name of Client(s) Exiting Client ID

Reason for Leaving Criminal Disagreement with Left for housing opp. Completed Program Completed Step activity/violence rules/persons Before completing program

Needs could not be Non-compliance with Non-payment of rent Other Reached maximum met program time allowed

Unknown/Disappeared

Destination (Where will you stay tonight?) Place not meant for Emergency Shelter Transitional Housing habitation (e.g. vehicle, Hotel or motel paid for Deceased (including hotel or for homeless persons abandoned building, without emergency motel paid for with an (including homeless bus/train/subway shelter voucher emergency shelter youth) station/airport or voucher) outside)

Rental by client, no Rental by client, with Rental by client, with Rental by client, Residential project or ongoing housing VASH subsidy GPD TIP (transition-in- With other ongoing halfway house with no subsidy (Veterans Affairs) place) subsidy subsidy homeless criteria

Hospital or other Staying or living with Staying or living with Staying or living with residential non- Psychiatric hospital or family, permanent family, temporary friends, permanent psychiatric medical other psychiatric tenure tenure tenure P a g e 1 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017

facility facility

Staying or living with Jail, prison or juvenile Substance abuse Moved from on Moved from one friends, temporary detention facility treatment facility or HOPWA funded HOPWA funded tenure detox center project to HOPWA PH project to HOPWA TH

Owned by client, no Owned by client, with Permanent housing ongoing housing ongoing housing (other than RRH)for Long-term care facility Safe Haven (non in subsidy subsidy formerly homeless or nursing home Alameda Co.) persons

Foster care home or Rental by client, with foster care group Client doesn’t know Client refused Other RRH or equivalent home

Any Adult in the Household currently receiving income? Yes (identify below) No

Source Amount Recipient(s) Source Amount Recipient(s) Alimony or other spousal support $ Social Security $

Income (SSI) Cash assistance/TANF $ Social Sec Disability $

Income (SSDI) Child Support $ Unemployment $

Earned Income $ VA Service $

Connected Disability Pension from a former job $ Veteran’s Pension $

Retirement from Social Security $ Worker’s $

Compensation Private Disability Insurance $ General Assistance $

Other Sources? $ Other Sources? $

Source ______Source ______

Total Monthly Income $ Total Monthly Income $ (record separately for each adult) (record separately for each adult)

Any adult in the Household currently receiving Non-Cash Benefits? Yes No

Source Recipient(s) Source Recipient(s) Supplemental Nutrition Assistance Other:

Program (SNAP/CalFresh) ______

Special Supplemental, Nutrition

Program for Women, Infants, and Children (WIC) TANF transportation services

Other TANF-funded services

P a g e 2 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017

Is anyone in the Household receiving Health Insurance? Yes No

Source Recipient(s) Source Recipient(s) Medicaid Employer-provided

Health Insurance Medicare Health insurance

obtained through COBRA State Children’s Health Insurance Private Pay Health

Program (SCHIP) Insurance Veteran’s Administration (VA) State Health Insurance

Medical Services for Adults Indian Health Services Program

Other:______

Disability Information: Name Condition Expected to be of long-continued Expected to and indefinite duration and substantially impair substantially impairs ability to live ability to live independently: independently: Physical Drug Abuse Yes Yes

Mental Health No No Developmental Alcohol HIV/AIDS

Chronic Health Condition

Physical Drug Abuse Yes Yes

Mental Health No No Developmental

Alcohol HIV/AIDS

Outreach Date of Contact: Location: Place not meant for habitation

Service setting, non-residential / / Service setting, residential

Start Date: End Date:

/ / / /

Education What is the highest level of school that you have completed?

Less than Grade 5 Grade 5-6 Grades 7-8 Grades 9-11

Grade 12 School program does not have grade levels GED Some college

Associate degree Bachelor’s degree Graduate degree Vocational certification

Client doesn’t know Client refused

School Status Attending School Regularly Attending School Regularly Graduated High School

Suspended Expelled Client doesn’t know

Employment Are you presently employed? Yes No Client doesn’t know Client refused

If employed, is this permanent, temporary or seasonal work? Full-time Part-time Seasonal Client doesn’t know Client refused

If No, Why not Employed?

Looking for work Unable to work Not Looking for work Data no collected

Health Status General Health Status Excellent Poor

Very good Client doesn’t know

Good Client refused

Fair Data not collected

Dental Health Status Excellent Poor

Good Client refused

Mental Health Status Excellent Poor

Good Client refused

Ever received anything in exchange for sex (e.g. Yes No Client refused money, food, drugs, or shelter)? Client doesn’t know Data not collected

If yes, for “received anything in exchange for sex”, Yes No Client refused has this occurred in the last three months? Client doesn’t know Data not collected

If yes, for “received anything in exchange for sex”, 1 - 3 4 - 7 8 – 11 How many times? 12 or more Client refused Client doesn’t know Data not collected

If yes, for “received anything in exchange for sex”, Yes No Client refused Ever made/persuaded to have sex in exchange for something? Client doesn’t know Data not collected

If yes, for “ever made/persuaded to have sex in Yes No Client refused exchange for something”, has this occurred in the last three months? Client doesn’t know Data not collected

Ever afraid to quit/leave work due to threats of Yes No Client refused violence to yourself, family, or friends? Client doesn’t know Data not collected

Ever promised work where work or payment was Yes No Client refused different than you expected? Client doesn’t know Data not collected

If yes, for either “Workplace violence threats” or Yes No Client refused “Workplace promise difference” Felt forced, pressured, or tricked into continuing the job? Client doesn’t know Data not collected

If yes, for either “Workplace violence threats” or Yes No Client refused “Workplace promise difference” In the last three months? Client doesn’t know Data not collected

Project Completion Status Completed project

Youth voluntarily left early

Youth was expelled or otherwise involuntarily discharged from project

If left early, select the major reason Left for other opportunities – Independent living Left for other opportunities – Education

Left for other opportunities – Military

Left for other opportunities – Other

Needs could not be met by project

If expelled or involuntarily discharged, select the Criminal activity/destruction of major reason property/violence Non-compliance with project rules

Non-payment of rent/occupancy charge

Reached maximum time allowed by project

Project terminated

Unknown/disappeared

Counseling received by client Yes No

Identify the type of counseling received Individual

Family

Group – Including peer counseling

Number of sessions received by exit

Total number of sessions planned in youth’s treatment or service plan

A plan is in place to start or continue counseling Yes No after exit

Exit destination safe – as determined by the client Yes No Client refused

Client doesn’t know Data not collected

Exit destination safe – as determined by the Yes No project/caseworker Worker doesn’t know

Client has permanent positive adult connections Yes No outside of project Worker doesn’t know

Client has permanent positive peer connections Yes No outside of project Worker doesn’t know

Client has permanent positive community Yes No connections outside of project Worker doesn’t know

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