Common Assessment Form
Assessment Completed By:
Phone:
Date Completed:
Email:
Shelter Name:
Shelter Case Manager:
Phone #:
Email:
Head of Household: BASNet Unique ID Number: _____________________________
First Name:
MI:
Last name:
Suffix:
Relationship to Head of Household: Self
SS#: _______ - _______ - ____________
Race:
DOB (M/D/Yr.):
Ethnicity: ____ Hispanic/Latino
____ Non-Hispanic/Latino
Homeless: ___ Yes ___ No
Chronically Homeless: ___ Yes ____No
Extent of Homelessness:





Gender:
Housing Status:




First time homeless
1-2 times homeless
Chronic:1 year or more
Chronic: 4 times in pass 3 years
Multiple times but not fit the chronic definition
Employed: _____Y ______N
Literally homeless
Housed and at imminent risk of losing housing
Housed and at-risk of losing housing
Stably housed
Highest Grade Completed: ___________
Domestic Violence: ____ Y _____ N
If yes, when did last incident occur:
 less than 3 months  3-6 months ago
 from 6 to 12 months ago
 more than a year ago  Don’t know  Refused
Veteran Status: (Have you served in the military?)
____Y _____ N
Residence Prior to Entering Program: (Where did you sleep last night?)
 Emergency shelter, including hotel or motel paid for with
emergency shelter voucher
 Transitional housing for homeless persons(including homeless
youth)
 Permanent housing for formerly homeless persons(such as SHP,
S+C, or SRO Mod Rehab)
 Psychiatric hospital or other psychiatric facility
 Substance abuse treatment facility/detox
 Hospital (non-psychiatric)
 Jail, prison, or juvenile detention facility
 Staying or living in family member’s room, apartment or house
 Staying or living in friend’s room, apartment or house
 Hotel or motel paid without emergency voucher
 Foster care home or group home
 Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere outside);
Name of: __________________________________________
Name of: __________________________________________
Name of: __________________________________________
Name of: __________________________________________
Name of: __________________________________________
Length of Stay in Residence Prior to Entering
Program:
 One week or less
 More than one week, less than one month
1
inclusive of “non-housing service site ( outreach programs only)”
 Safe Haven
 Rental by client, with VASH housing subsidy
 Rental by client, with other (non-VASH) ongoing housing subsidy
 Rental by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Owned by client, no ongoing housing subsidy
 Other: _______________________________________________





One to three months
More than three months, less than one year
One year or longer
Don’t Know
Refused
INCOME RECEIVED PAST 30 DAYS SOURCE OF INCOME
Yes No
If yes,
Start Date: _____________
End Date: ______________
TOTAL MONTHLY INCOME
$_______________________
Earned Income $_________
Unemployment Insurance $_________
Supplemental Security Income (SSI):$_________
Social Security Disability Income
(SSDI):$_________
Private Disability Insurance $_________
Worker’s Compensation $_________
Temporary Assistance for Needy Families

General Assistance (GA) $_________
Retirement from Social Security $_________
Veteran’s Pension $________
Pension from Former Job $________
Child Support $________
Alimony/Other Spousal Support $________
Other Sources:
If Other: Describe ________________$________
(TANF):$_________

NON-CASH BENEFITS PAST 30 DAYS
Yes
No
Don’t Know
Refused
If yes,
Start Date: _____________
End Date: ______________
DISABLING CONDITION
Yes
No
Don’t Know
Refused
DISABILITY DETERMINATION
Yes
No
Don’t Know
Refused
SOURCE OF NONCASH BENEFIT
Food StampsSupplemental
Nutrition Assistance
Program 
MEDICAID
MEDICARE
SCHIP- State
Children’s Health
Insurance Program
Special
Supplemental
Nutrition Program
for WIC

Veteran’s Administration Medical Services
TANF Child Care Services
TANF Transportation Services
Other TANF-Funded Services
Section 8, Public Housing or rental assistance
Other Source ____________________
Temporary rental assistance
DISABILITY TYPE
Physical Disability
Developmental Disability
Alcohol Abuse*
Both alcohol and drug abuse*
Chronic Health Condition*
Drug Abuse
Physical/Medical*
Mental Health*
HIV/AIDS
Hearing Impaired
Vision Impaired
Dual Diagnosis
Other
*verification required
I9f
IF YES, RECEIVING SERVICES OR TREATMENT WHILE IN THE PROGRAM? Yes No Don’t Know Refused
START DATE : ____________________________
LONG-TERM CONDITION? Yes No Don’t Know Refused
END DATE: _____________________________
NOTE ON DISABILITY:
2
Household Member #1:
First Name:
MI:
Last name:
Suffix:
Relationship to Head of Household:
SS#: _______ - _______ - ____________
Race:
DOB (M/D/Yr.):
Ethnicity: ____ Hispanic/Latino
____ Non-Hispanic/Latino
Homeless: ___ Yes ___ No
Chronically Homeless: ___ Yes ____No
Extent of Homelessness:





Gender:
Housing Status:




First time homeless
1-2 times homeless
Chronic:1 year or more
Chronic: 4 times in pass 3 years
Multiple times but not fit the chronic definition
Literally homeless
Housed and at imminent risk of losing housing
Housed and at-risk of losing housing
Stably housed
Domestic Violence: ____ Y _____ N
If yes, when did last incident occur:
 less than 3 months  3-6 months ago
 from 6 to 12 months ago
Veteran Status: (Have you served in the military?)
____Y _____ N
 more than a year ago  Don’t know  Refused
Highest Grade Completed:
Household Member #2:
First Name:
MI:
Last name:
Suffix:
Relationship to Head of Household:
SS#: _______ - _______ - ____________
Race:
DOB (M/D/Yr.):
Ethnicity: ____ Hispanic/Latino
____ Non-Hispanic/Latino
Homeless: ___ Yes ___ No
Chronically Homeless: ___ Yes ____No
Extent of Homelessness:





Gender:
Housing Status:




First time homeless
1-2 times homeless
Chronic:1 year or more
Chronic: 4 times in pass 3 years
Multiple times but not fit the chronic definition
Literally homeless
Housed and at imminent risk of losing housing
Housed and at-risk of losing housing
Stably housed
Domestic Violence: ____ Y _____ N
If yes, when did last incident occur:
 less than 3 months  3-6 months ago
 from 6 to 12 months ago
Veteran Status: (Have you served in the military?)
____Y _____ N
 more than a year ago  Don’t know  Refused
Highest Grade Completed:
3
Household Member #3:
First Name:
MI:
Last name:
Suffix:
Relationship to Head of Household:
SS#: _______ - _______ - ____________
Race:
DOB (M/D/Yr.):
Ethnicity: ____ Hispanic/Latino
____ Non-Hispanic/Latino
Homeless: ___ Yes ___ No
Chronically Homeless: ___ Yes ____No
Extent of Homelessness:





Gender:
Housing Status:




First time homeless
1-2 times homeless
Chronic:1 year or more
Chronic: 4 times in pass 3 years
Multiple times but not fit the chronic definition
Literally homeless
Housed and at imminent risk of losing housing
Housed and at-risk of losing housing
Stably housed
Domestic Violence: ____ Y _____ N
If yes, when did last incident occur:
 less than 3 months  3-6 months ago
 from 6 to 12 months ago
Veteran Status: (Have you served in the military?)
____Y _____ N
 more than a year ago  Don’t know  Refused
Highest Grade Completed:
Household Member #4:
First Name:
MI:
Last name:
Suffix:
Relationship to Head of Household:
SS#: _______ - _______ - ____________
Race:
DOB (M/D/Yr.):
Ethnicity: ____ Hispanic/Latino
____ Non-Hispanic/Latino
Homeless: ___ Yes ___ No
Chronically Homeless: ___ Yes ____No
Extent of Homelessness:





Gender:
Housing Status:




First time homeless
1-2 times homeless
Chronic:1 year or more
Chronic: 4 times in pass 3 years
Multiple times but not fit the chronic definition
Literally homeless
Housed and at imminent risk of losing housing
Housed and at-risk of losing housing
Stably housed
Domestic Violence: ____ Y _____ N
If yes, when did last incident occur:
 less than 3 months  3-6 months ago
 from 6 to 12 months ago
Veteran Status: (Have you served in the military?)
____Y _____ N
 more than a year ago  Don’t know  Refused
Highest Grade Completed:
4
Why are you seeking assistance?
A. Prevention
Wants to keep current
housing
B. Diversion
Explore other options
rather than shelter
placement
C. Homeless
Placement into
homeless program
Needs to move, can no
longer stay in current
housing
Already in a shelter and
need permanent
housing (RRH Screening)
1. Calculate annual gross income
Total gross annual income = Last 30 days income (see above) x 12 = ___________
Household
Size
30% AMI
50% AMI
1
2
3
4
5
6
7
8
13,350
15,250
17,150
19,050
20,600
22,100
23,650
25,150
22,250
24,400
28,600
31,750
34,300
36,850
39,400
41,950
If A. Prevention or B. Diversion is checked go to Q2. If C. Homeless is checked go to Q4.
2. Does Household annual income exceed 30% of AMI?
o Yes – participant is not eligible. Make referrals to other possible resources for the household
o No – Go to question 3.
3. What is the current rent being paid?
__________
Does the rent exceed the current FMR? ______ Y _______ N
Studio
1 bedroom
2 bedroom
3 bedroom
4 bedroom
557
591
736
941
1065
If Yes – participant is not eligible for assistance in current unit.
Ask if interested in re-locating to less expensive housing ______ Y _______ N
If Yes – Go to Question 4.
If No – Cannot assist
4. What brought on your housing crisis? (Check as many as apply)
Asked to leave by
Household conflict (ex.
Other:
landlord
– divorce, arguments,
_____________________
etc.)
Court eviction by
Foreclosure on rental
landlord
property lived in
No utilities due to shutPerson living with is
off/arrears
now deceased
No utilities due to
Release from
problems with building
institution
Relocation from out of
Evicted by primary
Erie/Niagara area
tenant
Mortgage foreclosure
Substance Abuse
5
Doubled
Up/Overcrowded
Domestic Violence
Mental Health
Fire/Natural Disaster
Loss of Income:
Job/Reduced
Hours/Loss of Benefits
Aged out of Foster
Care
Health/Safety Violations
Health Condition
5. Have you ever been to a homeless shelter or another homeless assistance program before?
_____ Yes _____ No
If yes, where? ___________________________________________
When? (most recent) __________________________
6. Have you been to DSS for this emergency?
Y or N
Type of Assistance
Approved
Emergency Housing
In Progress
Denied
Sanctioned
Cash Assistance
Rent/Utility Arrears
If Y was it a loan? ____
If load was it repaid? ____
Food Stamps
Medicaid
Other: ______________
____________________
Has not been to DSS
If client has been denied or sanctioned, please explain: _____________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
7. Type of Assistance Needed:
Assistance with accessing benefits
Rental Arrears
If yes, how much? ___________________
Security Deposit
If yes, how much? ___________________
Utility Arrears/Deposit?
If yes, how much? ___________________
Moving Expenses
Conflict resolution w/whoever living with
(not DV)
Housing Search Assistance
Landlord mediation
6
Legal Services
Rental Application Fees
Other: _____________________
Storage
Rental Assistance/Subsidy
Other: _____________________________
8. Housing History: (Start with most recent and go back as far as possible up to five years)
Location
Type of Housing
Reason for Moving
Dates:
___ Rental: Apartment/SRO/house
___ Evicted/Asked to leave
From ________ To __________
Rental Subsidy: ___Y ___N
___ Building Condemned
Address: (Street, City, State, Zip,
What kind? ________________
___ DV
County)
___ Home Ownership
___ Fire/Natural Disaster
___ Program or Institution
___ Unable to pay rent
Name: __________________
___ Moved to new residence
___ Living w/family member or
___ Discharged
friend
___ Family/Friend Conflict
Landlord Name:
___ Other: ___________________
___ Other: ___________________
_____________________________
Landlord Address:
Landlord Phone:
Location
Dates:
From ________ To __________
Address: (Street, City, State, Zip,
County)
Landlord Name:
Type of Housing
___ Rental: Apartment/SRO/house
Rental Subsidy: ___Y ___N
What kind? ________________
___ Home Ownership
___ Program or Institution
Name: __________________
___ Living w/family member or
friend
___ Other: ___________________
_____________________________
Reason for Moving
___ Evicted/Asked to leave
___ Building Condemned
___ DV
___ Fire/Natural Disaster
___ Unable to pay rent
___ Moved to new residence
___ Discharged
___ Family/Friend Conflict
___ Other: ___________________
Type of Housing
___ Rental: Apartment/SRO/house
Rental Subsidy: ___Y ___N
What kind? ________________
___ Home Ownership
___ Program or Institution
Name: __________________
___ Living w/family member or
friend
___ Other: ___________________
_____________________________
Reason for Moving
___ Evicted/Asked to leave
___ Building Condemned
___ DV
___ Fire/Natural Disaster
___ Unable to pay rent
___ Moved to new residence
___ Discharged
___ Family/Friend Conflict
___ Other: ___________________
Landlord Address:
Landlord Phone:
Location
Dates:
From ________ To __________
Address: (Street, City, State, Zip,
County)
Landlord Name:
Landlord Address:
Landlord Phone:
7
Location
Dates:
From ________ To __________
Address: (Street, City, State, Zip,
County)
Landlord Name:
Type of Housing
___ Rental: Apartment/SRO/house
Rental Subsidy: ___Y ___N
What kind? ________________
___ Home Ownership
___ Program or Institution
Name: __________________
___ Living w/family member or
friend
___ Other: ___________________
_____________________________
Reason for Moving
___ Evicted/Asked to leave
___ Building Condemned
___ DV
___ Fire/Natural Disaster
___ Unable to pay rent
___ Moved to new residence
___ Discharged
___ Family/Friend Conflict
___ Other: ___________________
Type of Housing
___ Rental: Apartment/SRO/house
Rental Subsidy: ___Y ___N
What kind? ________________
___ Home Ownership
___ Program or Institution
Name: __________________
___ Living w/family member or
friend
___ Other: ___________________
_____________________________
Reason for Moving
___ Evicted/Asked to leave
___ Building Condemned
___ DV
___ Fire/Natural Disaster
___ Unable to pay rent
___ Moved to new residence
___ Discharged
___ Family/Friend Conflict
___ Other: ___________________
Landlord Address:
Landlord Phone:
Location
Dates:
From ________ To __________
Address: (Street, City, State, Zip,
County)
Landlord Name:
Landlord Address:
Landlord Phone:
8
Program Screening Tool
Barriers to Obtaining Housing
*Economic (Required)
____ No Source of Income
____ Insufficient Income
____ No Security Deposit
____ Other: __________________________
____ Criminal History
____ Rental History
____ History of evictions
____ No rental history
____ Bad landlord references
____ Other: _____________________
____Household Composition
____ Needs 4+ bedrooms
____ Age/gender/# of children
____ Has pets
____ Utility Issues
____ Has utility arrears
____ Not able to get utilities in own name
____ Insufficient or No Personal ID
____ Needs Special Accommodations
____ Handicapped accessibility
____ Other: ______________________
____ Sexual Orientation/Identification
____ Transportation
____ Domestic Violence
____ Credit History
____ Other: __________________________
Barriers to Housing Retention
____ Income is < 30% of AMI
____ Insufficient Emergency Cash Reserves
____ Basic Living Skills
____ Household Upkeep/Cleanliness
____ Poor budgeting skills
____ Landlord/Tenant Responsibilities
____ Other: ______________________
____ Credit Repair
____ Homelessness History
____ Never lived independently
____ Little or No Employment History
____ Household conflicts
____ Domestic Violence
____ Weak communication skills
____ Transportation
____ Physical Health Issues
____ Mental Health Issues
No hospitalizations/ER in last year (RRH)
In treatment (RRH, TH)
Not connected with MH system (TH, PSH)
____ Chemical Dependency Issues
6 mos. + sobriety (RRH)
< 6 mos. sobriety (TH)
Currently using (TH, PSH)
Notes:
9