HPRP HMIS Data Collection: INTAKE FORM

INTAKE / HMIS ENTRY FORM for the Unsheltered Provider

HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix)

DATE OF CONTACT COUNTY WHERE ARE THEY STAYING? (Describe in enough detail to find them again)

SSN (HoH) DATE OF BIRTH TELEPHONE NUMBER EMAIL ADDRESS

VETERAN STATUS (HoH) ETHNICITY (HoH) GENDER (HoH)  Did Not Serve Active  Non-Hispanic/Latino  Male  Transgender female to male Duty in the US (Transgender man) Military  Served Active Duty  Hispanic / Latino  Female  Transgender male to female in the US Military (Transgender woman)  Does not identify as male, female, or transgender

PRIMARY RACE (HoH) Check All That Apply

 American Indian or Alaskan  Black / African American  Native / Hawaiian/Other Pacific Islander (NH) Native (AI/AN) (B)  Asian (A)  White (W)  Client refused  Client doesn’t know PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS:

Relationship RACE(s) SOCIAL Hispanic DATE OF to HEAD OF (choose VET NAME SECURITY /Latino GENDER BIRTH HOUSEHOLD from the (Y/N) NUMBER (Y/N) selection above)

INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Over 3 Months and Impairs Ability to Live Independently Physical Developmental Chronic Health Condition Mental Health  Yes  No HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Physical Developmental Chronic Health Condition Mental Health  Yes  No HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Physical Developmental Chronic Health Condition Mental Health  Yes  No HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse

Created by COHHIO 1 10/16 CURRENT UNSHELTERED HOMELESS EPISODE: (please fill out separately for each adult if adults have different past living situations) Client Name (if multiple adults in the “Residence Prior Place not meant for Household with differing Residence to Project Entry” habitation Priors)

LENGTH OF STAY ZIP of Last Permanent Address More than 1 1 night or 90 days or more but   week, but less  less less than 1 year than 1 month 2 nights 1 year 1 to 3  to 1   or months week longer

TIME ON THE STREETS, EMERGENCY SHELTER, OR SAFE HAVEN Including this and any previous shelter stays or unsheltered episodes, Approximate Date / / Homelessness Started (Month/Day/Year): Total number of months homeless on the street, in ES Number of times the client has been on the street, in or SH in past 3 years? ES or SH in the past 3 years including today? Institutional stays of less than 90 days are not a break. Stays less than 7 days in other places are not a break. 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 or more 12 or more

ADULTS AFFECTED BY DOMESTIC VIOLENCE  YES  NO NAME EXTENT OF DOMESTIC VIOLENCE  Within past 3 months  Within the past 6-12 months  Within the past 3-6 months  More than 1 year ago Currently Fleeing? Yes  No

 Within past 3 months  Within the past 6-12 months  Within the past 3-6 months  More than 1 year ago Currently Fleeing? Yes  No

Created by COHHIO 2 10/16