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