HMIS #:
CM Name:
Project Entry Date:
Santa Cruz County HMIS
Standardized Intake: Adult Exit
This form is designed to be completed by a service provider while interviewing a client.
A separate Standardized Intake form should be completed for each member of the household.
Household Information Is client:  Single Adult
If check Single Adult
If checked Adult in Household
 Adult in Household
 Child
Go to Client Profile
Are you the Head of Household (HoH)?

Yes

No
If no, name of HoH:
How many adults in household?:
How many children in household?:
If checked Child
If you are in a household, what is
your relationship to the HoH?
Name of HoH:

Self ( head of household)

Head of household’s child
 Head of household’s spouse or partner
 Other relation to head of household)
 Other: non-relation member
Client Profile
First Name
Middle
Last Name
Social Security Number
U.S. Military Veteran
Form# I500-1-20141001

 Yes
 No
 Client Doesn’t Know
 Client Refused
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Santa Cruz County Standardized Intake
HMIS #
Reason for Leaving & Destination
Reason for Leaving
 Completed Program
 Criminal Activity/Violence
 Death
 Disagreement with rules/persons
 Left for housing opportunity
 Needs could not be met
 Non-compliance
 Non-payment of rent
 Reach max time allowed
 Other
 Client Doesn’t Know
 Client Refused
 Unkown/Disappeared
If Other, Specify:
Destination
If Other, Specify:
Form# I500-1-20141001
 Deceased
 Emergency shelter
 Foster care or foster care group home
 Hospital or other non-psychiatric medical facility
 Hotel or motel paid for w/o emergency shelter voucher
 Jail, prison or juvenile detention facility
 Long-term care facility or nursing home
 Moved from one HOPWA funded project to HOPWA PH
 Moved from one HOPWA funded project to HOPWA TH
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing subsidy
 Permanent housing for formerly homeless persons
 Place not meant for habitation
 Psychiatric hospital or other psychiatric facility
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GDP TIP subsidy
 Rental by client, with other ongoing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living with family, permanent tenure
 Staying or living with family, temporary tenure
 Substance abuse treatment facility or detox center
 Transitional housing for homeless persons
 Other
 No exit interview completed
 Client doesn’t know
 Client refused
 Data not collected

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HMIS #
Santa Cruz County Standardized Intake
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
Income and Benefits Information
Receiving Income from any source?
 Yes
 No
 Client Doesn’t Know
 Client Refused
Total Monthly Income
If not receiving a source below, please put 0
 Earned Income $
 Alimony or Other Spousal Support $
 Child Support $
 General Assistance $
 Pension or other retirement income $
 Private Disability $
 Retirement Income from Soc. Sec. $
 SSDI $
 SSI $
 TANF $
 Unemployment Insurance $
 VA Service Connected Disability $
 VA Non-Service Connected Disability $
 Workers Compensation $
 Other $
, Specify,
Receiving Non-cash benefit from any source?
 Yes
 Client Doesn’t Know
 No
 Client Refused
If not receiving a source below, please put 0
 Section 8, or other ongoing rent assist.$
 Special Supp. Nutrition for WIC $
 SNAP (Food Stamps) $
 TANF Child Care $
 TANF Transportation $
 Other TANF-Funded Services $
 Temporary Rental Assistance $
 Other Source $
, Specify
Health Insurance
Covered by Health Insurance?
Medicaid
Medicare
State Children’s Health Insurance
VA Medical Services
Form# I500-1-20141001
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 Yes
 No
 Client Doesn’t Know
 Client Refused
Employer Provided Health Insurance
Heath insurance through COBRA
Private Pay health insurance
State Health Insurance for Adults
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
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Santa Cruz County Standardized Intake
HMIS #
Disabilities
Disability of Long Duration?
 Yes
 Client Doesn’t Know
 No
 Client Refused
If yes, please complete the following for each disability type
Physical Disability
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused
Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused
Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
Expected to substantially impair
ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused
Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused
Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
Expected to substantially impair
ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused
Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused
Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
 Yes  No
 Client Doesn’t Know
 Client Refused
Expected to substantially impair
ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused

Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused

Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
Developmental Disability
Chronic Health Condition
HIV/AIDS
Form# I500-1-20141001
 Yes  No
 Client Doesn’t Know
 Client Refused
 Yes  No
 Client Doesn’t Know
 Client Refused
 Yes  No
 Client Doesn’t Know
 Client Refused
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HMIS #
Santa Cruz County Standardized Intake
Disabilities, Cont.
Mental Health Problem
Substance Abuse
 Yes  No
 Client Doesn’t Know
 Client Refused
 No
 Alcohol Abuse
 Drug Abuse
 Alcohol & Drug Abuse
 Client Doesn’t Know
 Client Refused
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused
Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused
Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
Expected to be of long-continued and
indefinite duration and substantially
impairs ability to live independently?
 Yes  No
 Client Doesn’t Know
 Client Refused
Documentation of the disability and
severity on file?
 Yes  No
 Client Doesn’t Know
 Client Refused
Currently receiving
services/treatment for this
disability?
 Yes  No
 Client Doesn’t Know
 Client Refused
Employment
Currently Employed
 Yes
 No
 Client Doesn’t Know
 Client Refused
 Permanent
 Temporary
 Seasonal
 Client Doesn’t Know
 Client Refused
If Employed, hours worked in a week
If Employed, Type
I (Adult client or Head of Household) certify that the information I have provided here is true/correct to the best of my knowledge.
Print Name of Client
Signature of Client
Date
Print Name of Intake Worker
Signature of Intake Worker
Date
Form# I500-1-20141001
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