CT Statewide Emergency Shelter Intake Revised 03/20/2017
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CT Statewide Emergency Shelter Intake Revised 03/20/2017 Instructions: The Emergency Shelter Intake is completed if a household cannot be diverted from homelessness and needs to access services in the homelessness system. The interviewer should have access to the information captured during the Diversion Screening (if it was conducted) as well as shelter stay history from HMIS (if there is a shelter history). Project Entry Date: ______Applicant (Head of Household) Information:
First Name: ______Last Name: ______
Middle Name: ______Suffix: ______
Name Data Quality: Full Name Reported Partial, Street Name, or Code Name reported Client Doesn't Know Client Refused
Date of Birth: __/___/_____ Approximate or Partial DOB Reported Client Doesn't Know Client Refused
Social Security Number: ______-______-______ Approximate or Partial SSN Reported Client Doesn't Know Client Refused
Gender: Male Female Transgender Male to Female Transgender Female to Male Does not Identify as Male, Female, or Transgender Client Doesn’t Know Client Refused If Other, please specify: ______
Ethnicity: Hispanic/Latino Non-Hispanic/Non-Latino Client Doesn’t Know Client Refused Race: White Black or African American Asian American Indian or Alaska Native Native Hawaiian/ Pacific Islander Client Doesn’t Know Client Refused
Veteran Status: Have you ever been on active duty in the U.S. Military? Yes No Client doesn’t know Client refused
Cell Phone: ______Work Phone: ______Email: ______Emergency Contact Name and Phone #: ______
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 1 Additional Household Member Demographics: See codes below Relationship Ethnicit Social to Head of Disabling Date of Gender y Race Security Household Veteran Condition Last Name First Name Middle Name Suffix Birth * * * Number * (Y/N) (Y/N)
*Ethnicity Codes: NH-Non Hispanic/Non-Latino H- Hispanic/Latino DK- Client Doesn’t Know CR-Refused *Race: W- White; B- Black or African American; A- Asian; AI/AN- American Indian and Alaska Native; NH/PI- Native Hawaiian/ Pacific Islander; DK- Client Doesn’t Know; CR- Client Refused *Gender: M - Male; F - Female; TMF - Transgender Male to Female; TFM - Transgender Female to Male; O - Other; DK - Client Doesn’t Know; CR - Client Refused *Head of Household’s: C - Child; SP - Spouse or Partner; ORM - Other Relation Member; ONR - Other Non-Relation Member If “YES” to Veteran Status:
DD214 Order Date (optional) ____/ ____/ ____ DD214 Receive Date (optional) ____/ ____/ ____ Service Connected Disability? Yes No Don't Know Refused Branch of military: Air Force Army Marines Navy Coast Guard Client Doesn’t Know Client Refused Other Date entered Service ____/ ____/ ____ Reserves? (optional) Yes No What was your discharge status: Honorable General under Honorable Conditions Under Other than Honorable Conditions Bad Conduct Dishonorable Uncharacterized Client Doesn’t Know Client Refused
Years of Service: ______to ______Months of Active Duty: ______
Served in a war zone: Yes No Don't Know Refused Theatre of Operations: World War II Korean War Vietnam War Persian Gulf War (Operation Desert Storm) Afghanistan (Operation Enduring Freedom) Iraq (Operation Iraqi Freedom) Iraq (Operation New Dawn) Other Peace-keeping Operations or Military Interventions
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 2 After reviewing the Diversion assessment information (if a Screen was conducted), discuss what led to their housing crisis and/or to seek shelter and what plans there are for future living arrangements.
If you don’t come back, where would you most likely go? (Formerly “What are your plans for future living arrangements and leaving the shelter”) (Describe): (Do not read responses. Ask question and then choose one.) HoH Only Emergency Shelter or hotel / motel paid w/ ES voucher Permanent housing for formerly homeless persons Staying or living with Family member, permanent tenure Foster care or foster care group Home Place not meant for human habitation Staying or living with Family member, temporary tenure Hospital/other residential non-psychiatric medical facility Psychiatric Hospital or other psychiatric facility Staying or living with Friend, permanent tenure Hotel / Motel paid without ES voucher Rental by client, no housing subsidy Staying or living with Friend, temporary tenure Jail, prison, or juvenile detention facility Rental by client, with VASH subsidy Substance Abuse treatment facility or detox center Long-term care facility or Nursing Home Rental by client, with GPD TIP subsidy Transitional housing for homeless persons Moved from one HOPWA funded project to HOPWA PH Rental by client, other ongoing housing subsidy Client doesn't know Moved from one HOPWA funded project to HOPWA TH Residential project or halfway house with no homeless Client refused Owned by client, no housing subsidy criteria Other Owned by client, with housing subsidy Safe Haven If Other, please explain: ______Client Served Location: ______Disabling Condition: Yes No Client Doesn't Know Client Refused Living Situation: Type of Residence: (Do not read responses. Ask question and then choose one.) Emergency Shelter or hotel / motel paid with ES voucher Permanent housing for formerly homeless persons (CoC Safe Haven Foster care or foster care group Home Project, HUD Legacy Program, HOPWA PH) Staying or living in a family member’s room, apartment or Hospital or other residential non-psychiatric medical Place not meant for human habitation house facility Psychiatric Hospital or other psychiatric facility Staying or living in a friend’s room, apartment or house Hotel / Motel paid without ES voucher Rental by client, no ongoing housing subsidy Substance Abuse treatment facility or detox center Interim Housing Rental by client, with VASH subsidy Transitional housing for homeless persons Jail, prison, or juvenile detention facility Rental by client, with GPD TID subsidy Client doesn't know Long-term care facility or Nursing Home Rental by client, other ongoing housing subsidy Client refused Owned by client, no housing subsidy Residential project or halfway house with no homeless Other Owned by client, with ongoing housing subsidy criteria If Other, please explain: ______Length of Stay in the Prior Living Situation? One night or less One month or more, but less than 90 days Client doesn’t know Two days to six nights 90 days or more, but less than one year Client refused One week or more, but less than one month One year or longer
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 3 Zip Code of Last Permanent Address: ______ Partial Don't Know Refused
Approximate Date Homelessness Started ____/____/____
Regardless of where they stayed last night-- Number of Times the Client Has Been Homeless on the Streets, in ES, or SH in the Past Three Years Including Today: Never in 3 Years Three Times Client refused One Time Four or More Times Two Times Client doesn’t know
Total Number of Months Homeless on the Streets, in ES, or SH in the Past Three Years: One Month ( this time is the first time) More than 12 months Client Refused 2-12 Months (Specify # of Months: ______) Client Doesn’t Know Client refused
Domestic Violence Survivor? (Head of Household and All Adults): Yes No Don't Know Refused If “YES:” When experience occurred? Within the past three months Six months to one year ago (excluding one year Client doesn’t know exactly) Three to six months ago (excluding six months Client refused exactly) One year ago or more If “YES:” Are you currently fleeing? Yes No Don't Know Refused Non-cash benefit from any source? ( All Clients ) Yes No Client doesn’t know Client refused Non-cash benefits received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. H HH H Member HH Head M 4 Me of e mb H House m er hold be 2 r 1 YES / YE YE YES / NO NO S S / Y / NO
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 4 N O (SNAP) Food Stamps
Special Supplemental Nutrition Program for WIC TANF Child Care Services TANF Transportation Other TANF Funded Services
Section 8, Public Housing or Rental Assistance Temporary Rental Assistance Client Doesn't know Client Refused Other (Please Specify): Health Insurance: Yes No Client Doesn't Know Client Refused Pregnancy Status: Yes No Client Doesn't Know Client Refused Data Not Collected If “Yes:” Due Date? ____/____/____
Disabling Conditions (All Clients)
Hea HH HH HH HH d of Member 1 Member 2 Member 3 Member 4 Household Disabling Condition (All Adults) Yes, No, Client Doesn’t Know, Client Refused N/A Physical Disability (All Clients) Yes, No, Client Doesn’t Know, Client Refused
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 5 If yes, Documentation of the disability and severity on file? Yes, No If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused If yes, Currently receiving services/treatment for this disability? Yes, No, Client Doesn’t Know, Client Refused Developmental Disability (All Clients) Yes, No, Client Doesn’t Know, Client Refused If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused If yes, Documentation of the disability and severity on file? Yes, No If yes, Currently receiving services/treatment for this disability? Yes, No, Client Doesn’t Know, Client Refused Chronic Health Condition (All Clients) Yes, No, Client Doesn’t Know, Client Refused If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, DK, Refused If yes, Documentation of the disability and severity on file? Yes, No If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused HIV/AIDS (All Clients) Yes, No, Client Doesn’t Know, Client Refused If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused If yes, Documentation of the disability and severity on file? Yes, No If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 6 Mental Health Problem (All Clients) Yes, No, Client Doesn’t Know, Client Refused If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused If yes, Documentation of the disability and severity on file? Yes, No If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused Substance Abuse (All Clients) No, Alcohol Abuse, Drug Abuse, Both Alcohol and Drug, Client Doesn’t Know, Client Refused If yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused If yes, Documentation of the disability and severity on file? Yes, No If yes, Currently receiving services/treatment for this condition? Yes, No, Client Doesn’t Know, Client Refused How Confirmed? Confirmed by Prior Evaluation or Clinical Records, Confirmed Through Assessment and Clinical Evaluation, Unconfirmed; Presumptive or Self-Report Primary Language Spoken: English Spanish Chinese Russian Arabic Portuguese Bengali French Malay, Indonesian German Japanese Farsi (Persian) Urdu Punjabi Vietnamese Tamil Javanese Korean Turkish Telugu Marathi Italian Thai Burmese Kannada Gujarati Polish Hindi Cantonese Haitian Creole Unknown Other: ______ Other contributing factors, ask each question individually (Head of Household and All Adults) : Criminal Justice Involvement: Yes No Client doesn’t know Client refused
Legal Eviction or Foreclosure: Yes No Client doesn’t know Client refused
Expense Exceed Income: Yes No Client doesn’t know Client refused
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 7 Was doubled up, could no longer stay with friend/family: Yes No Client doesn’t know Client refused What is the PRIMARY reason you are experiencing homelessness? (Do not read responses. Ask questions and then choose one.) Criminal Justice Involvement Doubled Up Substance Abuse Problem Domestic Violence Victim/Survivor HIV/AIDS Employment Legal Eviction Mental Health Problems Chronic Illness Exceed Income Physical Health Affects Income and/or Housing Developmentally Disabled Income received from any source? ( HoH and Adults Only ) Yes No Client doesn’t know Client refused Note: Income received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. HH Member HH Head of Household HH Member 3 HH Member 4 1 Member 2 Monthly Mont Monthly Income Type Monthly Amount Monthly Amount Amount hly Amount Amount Alimony or Other Spousal Support Child Support Earned/Employed Income General Assistance Pension From a Former Job Private Disability Insurance Retirement Income From Social Security SSDI SSI TANF Unemployment Insurance CT Statewide Shelter Intake Assessment (v3.20.2017) Page 8 VA Service- Connected Disability Compensation VA Non-Service- Connected Disability Pension Worker's Compensation Other: Client Income Total Type of Insurance Y IF NO (*Note: This is NOT Required except for HOPWA Programs)
applied; decision pending applied; client not eligible did not apply Medicaid insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible did not apply Medicare insurance type N/A client doesn’t know client refused State Children’s Health applied; decision pending applied; client not eligible did not apply Insurance Program insurance type N/A (CHIP) client doesn’t know client refused applied; decision pending applied; client not eligible did not apply Veterans Administration (VA) insurance type N/A Medical Services client doesn’t know client refused applied; decision pending applied; client not eligible did not apply Employer-Provided Health insurance type N/A Insurance client doesn’t know client refused applied; decision pending applied; client not eligible did not apply Health Insurance Obtained insurance type N/A through COBRA client doesn’t know client refused applied; decision pending applied; client not eligible did not apply State Health Insurance for Adults insurance type N/A client doesn’t know client refused Private Pay Health Insurance applied; decision pending applied; client not eligible did not apply insurance type N/A
CT Statewide Shelter Intake Assessment (v3.20.2017) Page 9 client doesn’t know client refused
applied; decision pending applied; client not eligible did not apply Indian Health Services Program insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible did not apply Other (Specify) insurance type N/A client doesn’t know client refused Health Insurance ( All clients ): Immediate Needs:
1. Are there any restrictions on where you (your family) can live? Yes No
Describe: 2. Do you have any preferences for a town or region of the state? Yes No
Describe: 3. Any urgent or emergency needs? Yes No
Describe: 4. Any special needs, disabilities or medical conditions? Yes No a. If yes, list: Household member name Special needs/Disabilities/ Conditions
5. Anyone on medications? Yes No
a. If yes, list: Household member name Medications
6. Anyone have a physical problem that limits mobility or Yes No ability to self-care? a. If yes, list Household member name Mobility/self-care issue
7. Does anyone have an active order of protection against Yes No an abuser/batterer? CT Statewide Shelter Intake Assessment (v3.20.2017) Page 10 a. If yes, identify Name of filer Name of respondent
8. Does HH Head have government issued ID? Yes No
9. Do any household members lack government issued ID? Yes No a. If yes, names and ages:
10. Does anyone in the household have a case manager or worker at any social services agency? Yes No
a. If yes, worker name and contact number:
Additional notes:
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