CT Statewide Emergency Shelter Intake Revised 03/30/15
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  Other  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 (ver2014.11.14)
Page 1
If “YES” to Veteran Status:
Branch of military:
 Air Force  Army
 Marines
 Navy
 Coast Guard
 Client Doesn’t Know  Client Refused  Other
 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
Years of Service: _____________________ to ___________________
Theatre of Operations:
Served in a war zone:
 Yes  No  Don't Know  Refused
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
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.)
 Emergency Shelter or hotel / motel paid for with ES voucher Permanent housing for formerly homeless persons
 Foster care or foster care group Home
 Place not meant for human habitation
 Hospital or other residential non-psychiatric medical facility Psychiatric Hospital or other psychiatric facility
 Hotel / Motel paid without ES voucher
 Rental by client, no housing subsidy
 Jail, prison, or juvenile detention facility
 Rental by yourself with VASH subsidy
 Long-term care facility or Nursing Home
 Rental by yourself with GPD TID subsidy
 Moved from one HOPWA funded project to HOPWA PH
 Rental by yourself other ongoing housing subsidy
 Moved from one HOPWA funded project to HOPWA TH
 Residential project or halfway house with no homeless
 Owned by client, no housing subsidy
criteria
 Owned by client, with housing subsidy
 Safe Haven
 Staying or living with Family member, permanent tenure
 Staying or living with Family member,
temporary tenure
 Staying or living with Friend, permanent tenure
 Staying or living with Friend, temporary tenure
 Substance Abuse treatment facility or detox center
 Transitional housing for homeless persons
 Client doesn't know
 Client refused
 Othe
If Other, please explain: ___________________________________________
Disabling Condition:  Yes  No  Client Doesn't Know  Client Refused
If “YES:” Currently Receiving Disabling Condition Services?  Yes  No  Client Doesn't Know  Client Refused
Confirm/Update Prior Housing Arrangements (Type of Residence):
Where did you stay last night? (Do not read responses. Ask question and then choose one.)
 Emergency Shelter or hotel / motel paid with ES voucher
 Foster care or foster care group Home
 Hospital or other residential non-psychiatric medical
facility
 Hotel / Motel paid without ES voucher
 Jail, prison, or juvenile detention facility
 Long-term care facility or Nursing Home
CT Statewide Shelter Intake Assessment (ver2015.03.30)
 Owned by client, no housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons
 Place not meant for human habitation
 Psychiatric Hospital or other psychiatric facility
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GPD TID subsidy
 Rental by client, other ongoing housing subsidy
 Residential project or halfway house with no homeless
criteria
 Safe Haven
 Staying or living in a family member’s room, apartment,
house
Page 2
 Staying or living in a friend’s room, apartment or house
 Substance Abuse treatment facility or detox center
 Transitional housing for homeless persons
 Client doesn't know
 Client refused
 Other If Other, please explain: ______________
How long have you been there? (Residence Prior to Program Entry - Length of Stay)
 One day or less
 Two days to one week
 More than one week, but less than one month
 One to three months
 More than three months, but less than one year
 One year or longer
Zip Code of Last Permanent Address: ________________________________
 Client doesn’t know
 Client refused
 Partial  Don't Know  Refused
Housing Status:
 Category 1 - Homeless
 Category 2 - At imminent risk of losing housing
 Category 3 - Homeless only under other federal
statutes
 Category 4 - Fleeing Domestic Violence
 At risk of homelessness
 Stably housed
 Client doesn't know
 Client refused
Domestic Violence Survivor?  Yes  No  Client Doesn't Know  Client Refused
If “YES:” When experience occurred?
 Within the past three months
 Three to six months ago (excluding six months
exactly)
 Six months to one year ago (excluding one year
exactly)
 One year ago or more
 Client doesn’t know
 Client refused
Non-Cash Benefit from any source?  Yes  No  Client doesn’t know  Client refused
Non-Cash Benefit Type
YES/NO
Section 8, Public Housing or
Rental Assistance
(SNAP) Food Stamps
 Yes  No
Special Supplemental Nutrition Program for WIC
Temporary Rental Assistance
TANF Transportation
 Yes  No
 Yes  No
 Yes  No
Other TANF Funded Services
 Yes  No
Other (Please Specify):
TANF Child Care Services
Client Doesn't know
Client Refused
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Health Insurance:  Yes  No  Client Doesn't Know  Client Refused
EMPLOYMENT/EDUCATION: Employed:  Yes  No  Client doesn’t know  Client refused
If “YES:” Type of Employment:  Full Time  Part Time  Seasonal / Sporadic (includes day labor)
Hours Worked: ______________
CT Statewide Shelter Intake Assessment (ver2015.03.30)
Page 3
If “NO:” Why Not Employed:  Looking for work  Unable to work  Not looking for work
General Health Status:  Excellent  Very Good  Good  Fair  Poor  Client doesn’t know  Client refused
(If Female) Pregnant:  Yes  No  Client doesn’t know  Client refused
(If Yes) Due Date: __________________________
School Status:
 Attending school regularly
 Attending school irregularly
 Graduated from high school
 Obtained GED
 Dropped Out
 Suspended
 Expelled
 Client Doesn’t Know
 Client Refused
Last Grade Completed:
 Less than Grade 5
 Grades 5-6
 Grades 7-8
 Grades 9-11
 Grade 12
 School program does not have grade levels
 GED
 Some College
 Client Doesn’t Know
 Client Refused
Vocational Training or Apprentice Certificate:  Yes  No  Client doesn’t know  Client refused
Number of Times the Client Has Been Homeless in Past Three Years*:
* A time being homeless is “a separate, distinct, and sustained stay on the streets and/or in a homeless emergency shelter”.
 0 (not homeless – Prevention only)
3
 1 (homeless only this once)
 4 or more
2
 Client doesn’t know
 Client refused
(If “4 or more” above) Total Number of Months Homeless in Past Three Years:
 12 or less months (Specify # of Months: ______)
 More than 12 months
 Client Doesn’t Know
 Client Refused
Total Number of Months Continuously Homeless Immediately Prior to Project Entry: Indicate the number of months the client has been continuously homeless
including the day of project entry. For partial months, 1 day to 30 days = 1 month. _______ (provide a numeric response)
Continuously Homeless for at Least One Year?
 No  Yes  Client Doesn’t Know  Client refused
Status Documented: Indicate if there is documentation in the client’s paper file or in the HMIS of the client’s length of homelessness (either continuously homeless,
the number of times homeless, or the number of months homeless in the past three years).
 Yes  No
Homeless Dates:
1: ____/____/____ to ____/____/____
CT Statewide Shelter Intake Assessment (ver2014.11.14)
2: ____/____/____ to ____/____/____
3: ____/____/____ to____/____/____
Page 4
4: ____/____/____ to ____/____/____
5: ____/____/____to ____/____/____
6: ____/____/____to ____/____/____
Disabling Conditions:
Physical Disability:  Yes  No  Client Doesn’t Know  Client refused
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:  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:  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
HIV/AIDS:  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
Mental Health Problem:  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:  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
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: _____________________________________________
CT Statewide Shelter Intake Assessment (ver2014.11.14)
Page 5
Other contributing factors, ask each question individually:
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
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
 Domestic Violence Victim/Survivor
 Legal Eviction
 Exceed Income
 Substance Abuse Problem
 Employment
 Chronic Illness
 Developmentally Disabled
 Doubled Up
 HIV/AIDS
 Mental Health Problems
 Physical Health Affects Income and/or Housing
Income received from any source?  Yes  No  Client doesn’t know  Client refused
Income Type
Alimony or Other Spousal Support
Child Support
Earned/Employed Income
Income Type
Monthly Amount
Monthly Amount
Unemployment Insurance
VA Service-Connected Disability
Compensation
VA Non-Service-Connected
Disability Pension
General Assistance
Worker's Compensation
Pension From a Former Job
Other:
Private Disability Insurance
Retirement Income From Social Security
SSDI
SSI
TANF
CT Statewide Shelter Intake Assessment (ver2014.09.29)
Client Income Total
Page 6
Health Insurance:
Type of Insurance
YES / NO
IF NO (*Note: This is NOT Required except for HOPWA Programs)
Medicare
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
State Children’s Health Insurance Program
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
Veterans Administration (VA) Medical Services
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
Employer-Provided Health Insurance
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
Health Insurance Obtained through COBRA
 applied; decision pending  applied; client not eligible  did not apply  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
 client doesn’t know  client refused
State Health Insurance for Adults
 applied; decision pending  applied; client not eligible  did not apply  insurance type N/A
 client doesn’t know  client refused
Medicaid
Additional notes:
CT Statewide Shelter Intake Assessment (ver2014.11.14)
Page 7
CT Statewide Shelter Intake Assessment (ver2014.11.14)
Page 8
Immediate Needs
1.
Are there any restrictions on where you (your family) can live?
Yes
No
Yes
No
Describe:
2.
Do you have any preferences for a town or region of the state?
Describe:
3.
Any urgent or emergency needs?
Yes
No
Describe:
4.
5.
Any special needs, disabilities or medical
conditions?
a. If yes, list:
Anyone on medications?
a.
6.
7.
If yes, list:
Anyone have a physical problem that limits
mobility or ability to self-care?
a. If yes, list
Does anyone have an active order of protection
against an abuser/batterer?
a. If yes, identify
8.
Does HH Head have government issued ID?
9.
Do any household members lack government
issued ID?
a. If yes, names and ages
10. Does anyone in the household have a case
manager or worker at any social services
agency?
a. If yes, worker name and contact
number
CT Statewide Shelter Intake Assessment (ver2014.11.14)
Yes
No
Household member name
Special needs/Disabilities/ Conditions
Yes
No
Household member name
Medications
Yes
No
Household member name
Mobility/self-care issue
Yes
No
Name of filer
Name of respondent
Yes
No
Yes
No
Household member without ID
Age
Yes
HH Member Name
No
Worker Name
Contact number
Page 9