Emergency Shelter Individual Discharge Assessment
Exit Member Reservation (Bedlist Enrollment) – End Date:_______________
Staff completing discharge: ____________________________ CM: _____________________
ECM ID#_______________
First Name: ___________________
Last Name: _______________________________________
Date of Birth: ____________________ Client Doesn’t Know. Client Refused.
MI___
Housing Status:
 Literally Homeless
 Housed and at imminent risk of losing housing
 Unstably housed and at-risk of losing housing
 Stably housed
 Don't know
 Refused
Reason for Leaving (check only one):
 Completed Program
 Criminal Activity/destruction of property/Violence
 Non-compliance with program
 Reached maximum time allowed by program
 Needs could not be met by program
 Other
 Death
 Disagreement with rules/persons
 Non-payment of rent/occupancy charge
 Unknown/Disappeared
 Left for housing opp. before completing program
Destination (check only one):
 Deceased
 Don’t Know
 Emergency shelter or hotel paid for w/voucher
 Foster care home or foster care group home
 Hospital (non-psychiatric)
 Jail, prison or juvenile detention facility
 Hotel/motel w/o emergency voucher
 Other
 Substance Abuse treatment facility or detox center
 Transitional housing for formerly homeless persons
 Permanent housing for formerly homeless persons
 Won’t Answer
 Owned, no subsidy
 Owned, with subsidy
 Place not meant for habitation
 Psychiatric hospital or other psychiatric facility
 Rental, no subsidy
 Rental, VASH subsidy
 Rental, (non-VASH) subsidy
 Safe Haven
 With family, permanent tenure
 With family, temporary tenure
 With friends, permanent tenure
 With friends, temporary tenure
Domestic violence survivor?  Yes  No  Don’t know  Refused
Non-Cash benefits:  Yes  No  Client doesn’t know  Client refused
If “Yes,” check all that apply below.
 (CHIP) State Children’s Health Insurance Program
 (SNAP) Food Stamps
 (VA) Veteran’s Administration Medical Services
 (WIC) Nutrition Program for Women, Infants, Children
 Temporary Rental Assistance
 Section 8, Public Housing, or other Rental Assist
 MEDICAID Health Insurance program
 MEDICARE Health Insurance program
 Other Source
 Other TANF-Funded Services
 TANF Child Care Services
 TANF Transportation Services
Employment Status:  Employed  Not employed  Don’t know  Refused
Hours Worked Last Week: ____________________
Looking For Work:
 Yes  No  Client doesn’t know  Client refused
Revised: 2014.04.17
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Emergency Shelter Individual Discharge Assessment
Currently in school or working toward a degree:
Highest grade completed:
 Yes  No  Don’t know  Refused
 No schooling completed
 Nursery school to 4th grade
 5th grade or 6th grade
 7th grade or 8th grade
 High School Diploma
 GED
 Refused
 9th grade
 10th grade
 11th grade
 12th grade, No diploma
 Post-secondary school
 Don't Know
Vocational training or apprenticeship cert:  Yes  No  Don’t know  Refused
General Health Status:  Excellent  Very Good  Good  Fair  Poor  Don’t know  Refused
Pregnant (If Female):  Yes  No  Don’t know  Refused
Disabling Conditions:
Physical Disability:  Yes  No  Client Doesn't know  Client Refused
If “yes:” Received Physical Disability services or treatment?  Yes  No  Client Doesn't know  Client Refused
Chronic Health Condition:  Yes  No  Client Doesn't know  Client Refused
If “yes:” Received Chronic Health services or treatment?  Yes  No  Client Doesn't know  Client Refused
Mental Illness:  Yes  No  Client Doesn't know  Client Refused
If “yes:” Expected to be long and impair one’s ability to live independently:  Yes  No  Client Doesn't know
 Client Refused
If “yes:” Received Mental Illness services or treatment?  Yes  No  Client Doesn't know  Client Refused
Developmentally Disabled:  Yes  No  Client Doesn't know  Client Refused
If “yes:” Received Developmental Disabled services or treatment?  Yes  No  Client Doesn't know  Client Refused
Substance Abuse:  No  Alcohol Abuse  Drug Abuse  Both Alcohol and Drug Abuse  Client Doesn't know
 Client Refused
If “Alcohol, Drug, or Both:” Expected to be long and impair one’s ability to live independently:  Yes  No
 Client Doesn't know  Client Refused
If “Alcohol, Drug, or Both:” Received Substance Abuse services or treatment?  Yes  No  Client Doesn't
know  Client Refused
HIV/AIDS Status:  Yes  No  Client Doesn't know  Client Refused
If “yes:” Received HIV/AIDS services or treatment?  Yes  No  Client Doesn't know  Client Refused
Area Median Income: CT 2014 SMI & Fed Poverty Tables
Income in last 30 days:  Yes  No  Client doesn’t know  Client refused
If Income equals "0", choose "No Financial Resources.”
Interval
Income Type
(Daily, Weekly, Biweekly, Monthly,
Semi Monthly, Annually)
Amount
Earned income (ie: employment income)
Revised: 2014.04.17
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Emergency Shelter Individual Discharge Assessment
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Veteran’s Disability Payment
Private Disability Insurance
Temporary Assistance for Needy Families
General Public Assistance (GA)
Retirement Income From Social Security
Veteran’s Pension
Pension from a Former Job
Child Support
Alimony or other spousal support
Other Income
No Financial Resources
Social Security Income
Worker’s Compensation
Client Income Total
Primary Language Spoken:  Chinese  Spanish  English  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
Additional Contributing Factors:
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
Primary Factor:
Homelessness Primary Factor (Must be one of the following questions with a Yes answer):
Criminal justice involvement
Domestic violence victim/survivor
Legal eviction
Exceed income
Doubled up
HIV/AIDS
Mental Health problems
Physical health affects income and/or housing
Substance abuse problem
Employment
Chronic illness
Developmentally disabled
Revised: 2014.04.17
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