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