<p> 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: </p><p>First Name: ______Last Name: ______</p><p>Middle Name: ______Suffix: ______</p><p>Name Data Quality:  Full Name Reported  Partial, Street Name, or Code Name reported  Client Doesn't Know  Client Refused </p><p>Date of Birth: __/___/_____  Approximate or Partial DOB Reported  Client Doesn't Know  Client Refused </p><p>Social Security Number: ______-______-______ Approximate or Partial SSN Reported  Client Doesn't Know  Client Refused </p><p>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: ______</p><p>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</p><p>Veteran Status: Have you ever been on active duty in the U.S. Military?  Yes  No  Client doesn’t know  Client refused</p><p>Cell Phone: ______Work Phone: ______Email: ______Emergency Contact Name and Phone #: ______</p><p>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)</p><p>*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:</p><p>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</p><p>Years of Service: ______to ______Months of Active Duty: ______</p><p>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</p><p>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. </p><p>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 </p><p>CT Statewide Shelter Intake Assessment (v3.20.2017) Page 3 Zip Code of Last Permanent Address: ______ Partial  Don't Know  Refused</p><p>Approximate Date Homelessness Started ____/____/____</p><p>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</p><p>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</p><p>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</p><p>CT Statewide Shelter Intake Assessment (v3.20.2017) Page 4 N O       (SNAP) Food Stamps</p><p> Special Supplemental Nutrition Program for      WIC       TANF Child Care Services       TANF Transportation       Other TANF Funded Services</p><p> 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? ____/____/____</p><p> Disabling Conditions (All Clients)</p><p>  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</p><p>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</p><p>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</p><p> Legal Eviction or Foreclosure:  Yes  No  Client doesn’t know  Client refused</p><p> Expense Exceed Income:  Yes  No  Client doesn’t know  Client refused</p><p>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)</p><p>   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 </p><p>CT Statewide Shelter Intake Assessment (v3.20.2017) Page 9   client doesn’t know  client refused</p><p>   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:</p><p>1. Are there any restrictions on where you (your family) can live? Yes No</p><p> Describe:  2. Do you have any preferences for a town or region of the state? Yes No</p><p> Describe:  3. Any urgent or emergency needs? Yes  No</p><p> Describe:  4. Any special needs, disabilities or medical conditions?   Yes   No a. If yes, list:  Household member name  Special needs/Disabilities/ Conditions    </p><p>5. Anyone on medications?   Yes   No</p><p> a. If yes, list:  Household member name  Medications     </p><p>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     </p><p>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     </p><p>8. Does HH Head have government issued ID?   Yes   No</p><p>9. Do any household members lack government issued ID?   Yes   No a. If yes, names and ages:</p><p>10. Does anyone in the household have a case manager or   worker at any social services agency?  Yes  No</p><p> a. If yes, worker name and contact number:</p><p>  Additional notes:   </p><p>  </p><p>  </p><p>  </p><p>  </p><p>CT Statewide Shelter Intake Assessment (v3.20.2017) Page 11</p>