SSVF Housing Individual Intake Assessment
Enrollment Date: ________________
ECM ID#_____________________
First Name: ________________________________________________ Last Name: ___________________________________________________ MI: ____
Social Security Number: __________-________-__________  Client Doesn't Know  Client Refused
Date of Birth: ____________  Client Doesn't Know  Client Refused
Gender:  Male  Female  Transgender Male to Female  Transgender Female to Male  Other  Client Doesn’t Know  Client Refused  Transgender
Housing Status:
 Literally Homeless
 Housed and at Imminent risk of losing housing
 Unstably housed and at-risk of losing their housing
 Stably housed
 Refused
 Don't know
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
HIV/AIDS Status:  Yes  No  Client doesn’t know  Client refused
If “yes:” Received HIV Services:  Yes  No  Client doesn’t know  Client refused
Veteran Status:
 Yes  No  Client doesn’t know  Client refused
If “yes:”
Branch of military:
Months of active duty:
Service Era:
 Air Force  Army  Marines  Navy  Other  Don’t Know  Refused
______________________________
 WWII  Between WWII and Korean War  Korean War  Between Korean and Vietnam War  Vietnam Era  Post Vietnam
 Persian Gulf Era  Post Sept. 11, 2001 Afghanistan/Iraq  Iraq (Operation Iraqi Freedom)  Iraq (Operation New Dawn)  Don’t
Know  Won’t Answer
Served in a war zone:
 Yes  No  Client doesn’t know  Client refused
Received friendly or hostile fire:  Yes  No  Client doesn’t know  Client refused
Discharge Status:
 Bad Conduct  Dishonorable  General  Honorable  Medical  Other  Don’t Know  Refused
Living Situation the night prior to program entry:
 Emergency Shelter
 Foster care or foster care group Home
 Hospital or other residential (non-psychiatric)
 Hotel or Motel paid w/o emergency hotel voucher
 Jail, prison, juvenile detention facility
 Long-term care facility or nursing home
 Other
Revised: 2014.01.02
 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
 Rental by client, no ongoing housing subsidy
 Rental by client, with ongoing housing subsidy
 Residential project or halfway house w/ no subsidy
 Safe Haven
 Staying or living in a family member’s room
 Staying or living in a friend’s room or apartment
 Substance abuse treatment or detox center
 Transitional housing for homeless persons
 Client Doesn't know
 Client Refused
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SSVF Housing Individual Intake Assessment
Length of stay at prior night's residence:
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One week or less
More than one week, but less than one month
One to three months
Client Refused
 More than three months, but less than one year
 One year or longer
 Client Doesn’t Know
Zip Code of Last Permanent Address: ________________________________  Full  Partial  Don't Know  Refused
Non-Cash benefits:  Yes  No  Client doesn’t know  Client refused
If “Yes,” check all that apply below.
 (CHIP) State Children’s Health Insurance Program
 (SNAP) Food Stamps
 (VA) Veteran’s Administration Medical Services
 (WIC) Nutrition Program for Women, Infants, Children
 MEDICAID Health Insurance program
 MEDICARE Health Insurance program
 Other Source
 Other TANF-Funded Services
 Section 8, Public Housing, or other Rental Assist
 TANF Child Care Services
 TANF Transportation Services
 Temporary Rental Assistance
How long since you had a home/perm place to live?
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Less than 1 month
1 to 2 months
2 to 3 months
More than 3 months but less than 6 months
More than 6 months but less than 1 year
 1 to 2 years
 Greater than 2 years
 Client Doesn't know
 Client Refuses to Answer
Area Median Income: CT 2014 SMI & Fed Poverty Tables
Income in last 30 days:  Yes  No  Client doesn’t know  Client refused
If Income equals "0", choose "No Financial Resources.”
Interval
Income Type
(Daily, Weekly, Biweekly, Monthly, Semi
Monthly, Annually)
Amount
Earned income (ie: employment income)
Unemployment Insurance
Supplemental Security Income (SSI)
Social Security Disability Income (SSDI)
Veteran’s Disability Payment
Private Disability Insurance
Revised: 2014.01.02
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SSVF Housing Individual Intake Assessment
Temporary Assistance for Needy Families
General Public Assistance (GA)
Retirement Income From Social Security
Veteran’s Pension
Pension from a Former Job
Child Support
Alimony or other spousal support
Other Income
No Financial Resources
Social Security Income
Worker’s Compensation
Client Income Total
Revised: 2014.01.02
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