CT HMIS - Coordinated Access Intake Assessment
Appointment Date: ________________
ECM ID#: _______________
Staff completing intake: ____________________________
Case Mgr: _______________
First Name: ___________________
Last Name: _______________________________________
MI___
Was the VI-SPDAT assessment administered?  Yes  No
If “Yes”, what was the score?
_______
Housing Status:
 Literally Homeless
 Housed and at imminent risk of losing housing
 Unstably housed and at-risk of losing housing
 Stably housed
 Client doesn't know
 Client Refused
 Yes  No  Client doesn’t know  Client refused
If “Yes:” Currently Receiving Disabling Condition Services:  Yes  No  Client doesn’t know  Client refused
Disabling Condition:
 Yes  No  Client doesn’t know  Client refused
 Air Force  Army  Marines  Navy  Other  Don’t Know  Refused
______________________________
 WWII  Between WWII and Korean War  Korean War  Between Korean and
Vietnam War  Vietnam Era  Post Vietnam  Persian Gulf Era  Post Sept. 11,
2001 Afghanistan/Iraq  Iraq (Operation Iraqi Freedom)  Iraq (Operation New
Dawn)  Don’t Know  Won’t Answer
Served in a war zone:
 Yes  No  Client doesn’t know  Client refused
Received friendly or hostile fire:  Yes  No  Client doesn’t know  Client refused
Discharge Status:
 Bad Conduct  Dishonorable  General  Honorable  Medical  Other
 Client doesn’t Know  Client Refused
Veteran Status:
If “yes:” Branch of military:
Months of active duty:
Service Era:
Living Situation the night prior to program entry:
 Emergency Shelter
 Foster care or foster care group Home
 Hospital or other residential (non-psychiatric)
 Hotel or Motel paid w/o emergency hotel voucher
 Jail, prison, juvenile detention facility
 Long-term care facility or nursing home
 Other
 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
 Rental by client, no ongoing housing subsidy
 Rental by client, with ongoing housing subsidy
 Residential project or halfway house w/ no subsidy
 Safe Haven
 Staying or living in a family member’s room
 Staying or living in a friend’s room or apartment
 Substance abuse treatment or detox center
 Transitional housing for homeless persons
 Client doesn't know
 Client Refused
Length of stay at prior night's residence:
 One week or less
 More than one week, but less than one month
 One to three months
 Client Refused
 More than three months, but less than one year
 One year or longer
 Client doesn’t Know
Zip Code of Last Permanent Address:
 Full  Partial  Client doesn’t know  Client refused
If Full or Partial, enter zip code:
_________________
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Domestic violence survivor?
If “yes,” when experience occurred?
 Within the past three months
 From six to one year
 Client Don't Know
 Yes  No  Client doesn’t know  Client refused
 Three to six months
 More than a year
 Client 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
 Employed  Not employed  Client doesn’t know  Client refused
Name of employment:
_______________________________________
Farmer:
 Farmer  Migrant Farm Worker  Seasonal Farm Worker
Employment tenure:
 Day Labor  Don’t know  Permanent  Refused  Seasonal
 Temporary
If Employed, Looking for additional work or hours?  Yes  No  Client doesn’t know  Client refused
Employment Status:
If Employed:
Currently in school or working toward a degree:
Highest grade completed:
 No schooling completed
 Nursery school to 4th grade
 5th grade or 6th grade
 7th grade or 8th grade
 High School Diploma
 GED
 Client Refused
 Yes  No  Don’t know  Refused
 9th grade
 10th grade
 11th grade
 12th grade, No diploma
 Post-secondary school
 Client doesn't know
General Health Status:  Excellent  Very Good  Good  Fair  Poor  Client doesn’t know  Client refused
Chronically Homeless & Disabling Conditions:
In last 3 years, the number of episodes:
 One, first time homeless
 Two or three times
 Four or more times
 Client doesn’t know
 Client refused
How long since you had a home/perm place to live?
 Less than 1 month
 1 to 2 months
 2 to 3 months
 More than 3 months but less than 6 months
 More than 6 months but less than 1 year
 1 to 2 years
 Greater than 2 years
 Client doesn't know
 Client refused
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Disabling Conditions:
Physical Disability:
 Yes  No  Client doesn’t know  Client refused
If “yes,” Currently receiving 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,” Currently receiving 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,” Currently receiving 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,” Currently receiving Developmental Disabled services or treatment?
 Yes  No  Client doesn’t know  Client refused
 No  Alcohol Abuse  Drug Abuse  Both Alcohol and Drug
Abuse  Client doesn’t know  Client refused
If “Alcohol, Drug, or Both:” Currently receiving Substance Abuse services or treatment?
 Yes  No  Client doesn’t know  Client refused
Substance Abuse:
HIV/AIDS Status:
 Yes  No  Client doesn’t know  Client refused
If “yes,” Currently receiving HIV/AIDS services or treatment?
 Yes  No  Client doesn’t know  Client refused
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
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
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CT HMIS - Coordinated Access Intake Assessment
Area Median Income:
Income in last 30 days:
CT 2014 SMI & Fed Poverty Tables
 Yes  No  Client doesn’t know  Client refused
If Income equals "0", choose "No Financial Resources” in the software application
Interval
Income Type
(Daily, Weekly, Biweekly, Monthly,
Semi Monthly, Annually)
Amount
Earned income (ie: employment income)
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
If Client is able to be DIVERTED, please fill out the following information
Exit Outcome:
 Diverted in place  Diverted with relocation
Diverted To:
 Family  Landlord Remediation  Friend (support person)  Other
If “other”:
____________________________________________________________
Received financial assistance?
 Yes  No
If “yes”, please fill out all assistance types provided to the household
Assistance Type
Amount
Utility Deposit
Utility Assistance
Rental Assistance
Rental/Security Deposit
Application Fees
Motel/Hotel Vouchers
Vehicle Maintenance
Moving Costs
Bus Tokens
Transportation
*** END OF COORDINATED ACCESS INTAKE QUESTIONS ***
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_____________________________
Internal Staff use ONLY
NEXT Steps for Coordinated Access

Complete Coordinated Access Referral by either
 Referring them to a program that has an opening - If space is available in an existing program within your
local network, the client should be enrolled in that program by the appropriate staff
 Adding them to the community waitlist -- If there is no space available in an existing program, you should
add the client to the Local Wait List within the Coordinated Access Program
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