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 10/01/2017Exit Date ServicePoint (HoH) ID: / /Project Name Head of Household Name SSN Last four digits first middle last suffixIf Partial Household Exit (if the whole household is existing, skip to Destination) Name of Client(s) Exiting Client IDReason for Leaving Criminal Disagreement with Left for housing opp. Completed Program Completed Step activity/violence rules/persons Before completing programNeeds could not be Non-compliance with Non-payment of rent Other Reached maximum met program time allowedUnknown/DisappearedDestination (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 criteriaHospital 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 facilityStaying 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 THOwned 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.) personsFoster care home or Rental by client, with foster care group Client doesn’t know Client refused Other RRH or equivalent homeAny Adult in the Household currently receiving income? Yes (identify below) NoSource 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 NoSource 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 servicesP a g e 2 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017Is anyone in the Household receiving Health Insurance? Yes NoSource 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 YesMental Health No No Developmental Alcohol HIV/AIDS Chronic Health ConditionPhysical Drug Abuse Yes YesMental Health No No Developmental Alcohol HIV/AIDS Chronic Health ConditionPhysical Drug Abuse Yes YesMental Health No No Developmental Alcohol HIV/AIDS Chronic Health ConditionPhysical Drug Abuse Yes YesMental Health No No DevelopmentalP a g e 3 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017Alcohol HIV/AIDS Chronic Health ConditionPhysical Drug Abuse Yes YesMental Health No No Developmental Alcohol HIV/AIDS Chronic Health ConditionOutreach Date of Contact: Location: Place not meant for habitationService setting, non-residential / / Service setting, residentialStart 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 9-11Grade 12 School program does not have grade levels GED Some collegeAssociate degree Bachelor’s degree Graduate degree Vocational certificationClient doesn’t know Client refusedSchool Status Attending School Regularly Attending School Regularly Graduated High SchoolSuspended Expelled Client doesn’t knowEmployment Are you presently employed? Yes No Client doesn’t know Client refusedIf employed, is this permanent, temporary or seasonal work? Full-time Part-time Seasonal Client doesn’t know Client refusedIf No, Why not Employed?P a g e 4 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017Looking for work Unable to work Not Looking for work Data no collectedHealth Status General Health Status Excellent PoorVery good Client doesn’t knowGood Client refusedFair Data not collected Dental Health Status Excellent PoorVery good Client doesn’t knowGood Client refusedFair Data not collectedMental Health Status Excellent PoorVery good Client doesn’t knowGood Client refusedFair Data not collectedEver received anything in exchange for sex (e.g. Yes No Client refused money, food, drugs, or shelter)? Client doesn’t know Data not collectedIf 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 collectedIf 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 collectedIf 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 collectedIf 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 collectedEver 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 collectedP a g e 5 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017Ever promised work where work or payment was Yes No Client refused different than you expected? Client doesn’t know Data not collectedIf 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 collectedIf 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 collectedProject Completion Status Completed projectYouth voluntarily left earlyYouth was expelled or otherwise involuntarily discharged from projectIf left early, select the major reason Left for other opportunities – Independent living Left for other opportunities – EducationLeft for other opportunities – Military Left for other opportunities – OtherNeeds 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 rulesNon-payment of rent/occupancy chargeReached maximum time allowed by projectProject terminatedUnknown/disappearedCounseling received by client Yes No Identify the type of counseling received Individual FamilyGroup – Including peer counselingNumber of sessions received by exitP a g e 6 | 7 HMIS Standard Exit Form for RHY Effective 10/01/2017Total number of sessions planned in youth’s treatment or service planA plan is in place to start or continue counseling Yes No after exitExit destination safe – as determined by the client Yes No Client refusedClient doesn’t know Data not collectedExit destination safe – as determined by the Yes No project/caseworker Worker doesn’t knowClient has permanent positive adult connections Yes No outside of project Worker doesn’t knowClient has permanent positive peer connections Yes No outside of project Worker doesn’t knowClient has permanent positive community Yes No connections outside of project Worker doesn’t knowP a g e 7 | 7

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

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