HMIS Child Exit Form - CoC Programs
Complete a separate form for each Child. [All Clients = Adults & Children]
Last Name:
Middle Name:
First Name:
Social Security #
Date of Birth
Project Name:
Project Exit Date:
Head of Household:
Staff Completing Exit:
HOUSING STATUS AT EXIT [ALL Clients]
Homeless
Fleeing domestic violence
At imminent risk of losing housing
At-risk of homelessness
Homeless only under other federal statutes
Stably Housed
Client doesn’t know
Client refused
REASON FOR LEAVING [ALL Clients]
Left for a housing opportunity
before completing program
Completed Program
Non-payment of rent /
occupancy charge
Non-compliance with program
Criminal activity/destruction of
property / violence
Reached maximum time
allowed by program
Needs could not be met by
program
Disagreement with rules/person
Death
Client doesn’t
know
Unknown /
disappeared
Other
DESTINATION [ALL Clients]
Deceased
Emergency shelter, including hotel or motel
paid for with emergency shelter voucher
Rental by client, with VASH subsidy
Rental by client, with GPD TIP subsidy
Foster care home or group home
Hospital or other residential nonpsychiatric medical facility
Hotel or motel paid for without emergency
shelter voucher
Jail, prison or juvenile detention facility
Long-term care facility or nursing home
Owned by client, NO ongoing housing subsidy
Owned by client, WITH ongoing housing
subsidy
Permanent housing for formerly homeless
persons (such as: CoC project)
Place not meant for habitation (e.g. vehicle,
abandoned building, bus/train/subway station,
airport or anywhere outside)
Psychiatric hospital or other psychiatric facility
Rental by client, NO ongoing housing subsidy
CHILD HMIS Exit Form - CoC Programs
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Rental by client, with other ongoing
Housing subsidy
Residential project or halfway house
With no homeless criteria
Staying or living with family, permanent
tenure (e.g. room, apartment or house)
Staying or living with family, temporary
tenure (e.g. room, apartment or house)
Staying or living with friends, permanent
tenure (e.g. room, apartment or house)
Staying or living with friends, temporary
tenure (e.g. room, apartment or house)
Substance abuse treatment facility or
detox center
Transitional housing for homeless
persons (including homeless youth)
Other (Specify “Other”)
No exit interview completed
Client doesn’t know
Client refused
Revised 08.14.15
HMIS Child Exit Form - CoC Programs
PHYSICAL DISABILITY [All Clients]
No
Client doesn’t know
Yes
Client refused
IF “YES” TO PHYSICAL DISABILITY – SPECIFY
Receiving services for physical disability
Is the physical disability expected to be of long-continued
and indefinite duration and substantially impairs ability to
live independently.
Documentation of the disability and severity on file
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
No
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
DEVELOPMENTAL DISABILITY [All Clients]
No
Client doesn’t know
Yes
Client refused
IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY
Receiving services for developmental disability
Is the developmental disability expected to substantially
impair ability to live independently?
Documentation of the disability and severity on file
CHRONIC HEALTH CONDITION [All Clients]
No
Client doesn’t know
Yes
Client refused
IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to be of long-continued and
indefinite duration and substantially impairs ability to live
independently.
Documentation of the disability and severity on file
HIV-AIDS [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO HIV-AIDS – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to substantially impair ability to
live independently?
Documentation of the disability and severity on file
CHILD HMIS Exit Form - CoC Programs
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No
Yes
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
Revised 08.14.15
HMIS Child Exit Form - CoC Programs
MENTAL HEALTH PROBLEMS [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO MENTAL HEALTH PROBLEMS – SPECIFY
Currently receiving services/treatment for this condition
Is the condition expected to be of long-continued and
indefinite duration and substantially impairs ability to live
independently.
Documentation of the disability and severity on file
No
Yes
No
Client doesn’t know
Client refused
Client doesn’t know
Yes
Client refused
No
Yes
SUBSTANCE ABUSE PROBLEMS [All Clients]
No
Both alcohol and drug abuse
Alcohol abuse
Client doesn’t know
Drug abuse
Client refused
IF “YES” TO ALCOHOL ABUSE, DRUG ABUSE OR BOTH – SPECIFY
No
Currently receiving services/treatment for this condition
Yes
Is the condition expected to be of long-continued and
No
indefinite duration and substantially impairs ability to live
Yes
independently.
Documentation of the disability and severity on file
No
Client doesn’t know
Client refused
Client doesn’t know
Client refused
Yes
COVERED BY HEALTH INSURANCE [All Clients]
No
Yes
Client doesn’t know
Client refused
IF “YES” TO HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS
MEDICAID (aka Medi-Cal)
Employer Provided
MEDICARE
Obtained through COBRA
SCHIP (Do Not Use)
Private Pay Health Insurance
VA Medical
State Health Insurance for Adults (Do Not Use)
CHILD HMIS Exit Form - CoC Programs
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Revised 08.14.15
HMIS Child Exit Form - CoC Programs
EMPLOYMENT
[All Clients, For Age 16 & Over]
Employed: ☐Yes ☐No ☐Don’t know ☐Refused (If yes, Hours worked Last Week: _____)
Employment Tenure/Stability: ☐Permanent ☐Temp ☐Seasonal ☐Don’t know ☐Refused
If Not Employed, Seeking Employment: ☐Yes ☐No ☐Don’t know ☐Refused
EDUCATION
[All Clients, For Age 5 & over]
Currently Enrolled in School: ☐Yes ☐No ☐Don’t know ☐Refused
If Enrolled:
Vocational Training or Apprenticeship: ☐Yes ☐No ☐Don’t know ☐Refused
Name of school enrolled:
Is child connected to the HUD homeless liaison: ☐Yes ☐No ☐Don’t know ☐Refused
Type of School: ☐Public
☐Parochial or other Private School
Highest Educational Level Completed:
☐
☐
☐
☐
☐
No School Completed
Nursery School to 4th Grade
5th or 6th Grade
7th or 8th Grade
9th Grade
☐
☐
☐
☐
☐
10th Grade
11th Grade
12th Grade (No Diploma)
GED
High School Diploma
☐ Postsecondary School
☐ Don’t know
☐ Refused
If Not Enrolled:
Date of the last enrollment:
Barrier to Enrolling Child in School:
☐
☐
☐
☐
☐
☐
None
Residency requirements
Availability of school records
Birth Certificate
Legal Guardianship required
Transportation
CHILD HMIS Exit Form - CoC Programs
☐
☐
☐
☐
☐
☐
Lack of available preschool program
Immunization requirements
Physical examination records
Other
Don’t Know
Refused
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Revised 08.14.15