The URL can be used to link to this page

Home My WebLink Aboutachmis-client-profile-and-intake-form Alameda County HMIS CLARITY HMIS: HUD-CoC PROJECT INTAKE FORM Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member. PROJECT START DATE [All Clients] / / Month Day Year TRANSLATION ASSISTANCE NEEDED? [Head of Household] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO TRANSLATION ASSISTANCE NEEDED – INDICATE PREFERRED LANGUAGE ○ Albanian ○ Hebrew ○ Punjabi ○ American Sign Language ○ Hindi ○ Romanian ○ Amharic ○ Hmong ○ Russian ○ Arabic ○ Hungarian ○ Serbian ○ Armenian ○ Igbo ○ Sinhalese ○ Bengali ○ Indonesian ○ Slovak ○ Bosnian ○ Italian ○ Somali ○ Bulgarian ○ Japanese ○ Spanish ○ Burmese ○ Khmer ○ Swedish ○ Chinese ○ Korean ○ Tagalog ○ CroaCan ○ LaoCan ○ Tamil ○ Czech ○ Lithuanian ○ Telugu ○ Dutch ○ Malayalam ○ Thai ○ English ○ Mam ○ Turkish ○ Farsi ○ Marathi ○ Ukrainian ○ French ○ Navajo ○ Urdu ○ German ○ Nepali ○ Vietnamese ○ Greek ○ Polish ○ Yiddish ○ HaiCan Creole ○ Portuguese ○ Yoruba ○ Different Preferred Language (specify): ○ Client doesn’t know ○ Client prefers not to answer ○ Data not collected SOCIAL SECURITY NUMBER [All Clients] - - QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Approximate or partial SSN reported ○ Client prefers not to answer ○ Data not collected CURRENT NAME [All Clients ] N/A Last ○ First ○ Middle ○ Suffix ○ QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client prefers not to answer ○ Data not collected DATE OF BIRTH [All Clients] / / Age: Month Day Year QUALITY OF DATE OF BIRTH ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client prefers not to answer ○ Data not collected GENDER [All Clients] ○ Woman (Girl, if child) ○ Questioning ○ Man (Boy, if child) ○ Different Identity (specify): ○ Culturally Specific Identity (e.g., Two-Spirit) ○ Client doesn’t know ○ Transgender ○ Client prefers not to answer ○ Non-Binary ○ Data not collected SEXUAL ORIENTATION [For CoC: YHDP and PSH funded programs – Adults and Head of Household] ○ Heterosexual ○ Other ○ Gay If Other please specify: ○ Lesbian ○ Client doesn’t know ○ Bisexual ○ Client prefers not to answer ○ Questioning/Unsure ○ Data not collected RACE AND ETHNICITY (Select all applicable) [All Clients] ○ American Indian, Alaska Native, or Indigenous ○ Native Hawaiian or Pacific Islander ○ Asian or Asian American ○ White ○ Black, African American, or African ○ Client doesn’t know ○ Hispanic/Latina/e/o ○ Client prefers not to answer ○ Middle Eastern or North African ○ Data not collected VETERAN STATUS [All Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Korean War ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Vietnam War ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Persian Gulf War (Desert Storm) ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Afghanistan (Operation Enduring Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Iraq (Operation Iraqi Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Iraq (Operation New Dawn) ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Theater of Operations: Other peace-keeping operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Branch of the Military ○ Army ○ Space Force ○ Air Force ○ Client doesn’t know ○ Navy ○ Client prefers not to answer ○ Marines ○ Data not collected ○ Coast Guard Discharge Status ○ Honorable ○ Uncharacterized ○ General under honorable conditions ○ Client doesn’t know ○ Other than honorable conditions (OTH) ○ Client prefers not to answer ○ Bad Conduct ○ Data not collected ○ Dishonorable What is the City, State, of last permanent housing? ○ Alameda ○ San Leandro ○ Albany ○ San Lorenzo ○ Berkeley ○ Sunol ○ Castro Valley ○ Union City ○ Dublin ○ Other unincorporated Alameda County ○ Emeryville ○ Other Bay Area County: Contra Costa ○ Fremont ○ Other Bay Area County: Marin ○ Hayward ○ Other Bay Area County: San Francisco ○ Livermore ○ Other Bay Area County: San Mateo ○ Newark ○ Other Bay Area County: Santa Clara ○ Oakland ○ Other California County ○ Piedmont ○ Other State ○ Pleasanton ○ Other Country What is the City, State, of high school last attended? ○ Alameda ○ San Leandro ○ Albany ○ San Lorenzo ○ Berkeley ○ Sunol ○ Castro Valley ○ Union City ○ Dublin ○ Other unincorporated Alameda County ○ Emeryville ○ Other Bay Area County: Contra Costa ○ Fremont ○ Other Bay Area County: Marin ○ Hayward ○ Other Bay Area County: San Francisco ○ Livermore ○ Other Bay Area County: San Mateo ○ Newark ○ Other Bay Area County: Santa Clara ○ Oakland ○ Other California County ○ Piedmont ○ Other State ○ Pleasanton ○ Other Country What is the City, State, of family residence when born? ○ Alameda ○ San Leandro ○ Albany ○ San Lorenzo ○ Berkeley ○ Sunol ○ Castro Valley ○ Union City ○ Dublin ○ Other unincorporated Alameda County ○ Emeryville ○ Other Bay Area County: Contra Costa ○ Fremont ○ Other Bay Area County: Marin ○ Hayward ○ Other Bay Area County: San Francisco ○ Livermore ○ Other Bay Area County: San Mateo ○ Newark ○ Other Bay Area County: Santa Clara ○ Oakland ○ Other California County ○ Piedmont ○ Other State ○ Pleasanton ○ Other Country NOTES RELATIONSHIP TO HEAD OF HOUSEHOLD [All Client Households] ○ Self ○ Head of household - other relation to member ○ Head of household’s child ○ Other: non-relation member ○ Head of household’s spouse or partner ENROLLMENT CoC [only if multiple CoC’s] ______________________ WHEN CLIENT WAS ENGAGED [Street Outreach Only or Night by Night Emergency Shelter] Date of Engagement: ____/____/__________ IN PERMANENT HOUSING [Permanent Housing Projects, for Head of Household] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-In Date: ____/____/__________ PRIOR LIVING SITUATION TYPE OF RESIDENCE [Head of Household and Adults] ○ Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport, or anywhere outside) ○ Hotel or motel paid for without emergency shelter voucher ○ Emergency shelter, including hotel or motel paid for with emergency shelter voucher, or Host Home shelter ○ Host Home (non-crisis) ○ Safe Haven ○ Staying or living in a friend’s room, apartment, or house ○ Foster care home or foster care group home ○ Staying or living in a family member’s room, apartment or house ○ Hospital or other residential non-psychiatric medical facility ○ Rental by client, no ongoing housing subsidy ○ Jail, prison or juvenile detention facility ○ Rental by client, with ongoing housing subsidy ○ Long-term care facility or nursing home ○ Owned by client, with on-going housing subsidy ○ Psychiatric hospital or other psychiatric facility ○ Owned by client, no on-going housing subsidy ○ Substance abuse treatment facility or detox center ○ Client doesn’t know ○ Transitional housing for homeless persons (including homeless youth) ○ Client prefers not to answer ○ Residential project or halfway house with no homeless criteria ○ Data not collected IF “RENTAL BY CLIENT, WITH ONGOING HOUSING SUBSIDY” – SPECIFY: ○ GPD TIP housing subsidy ○ Emergency Housing Voucher ○ VASH Housing subsidy ○ Family Unification Program Voucher (FUP) ○ RRH or equivalent subsidy ○ Foster Youth to Independence Initiative (FYI) ○ HCV voucher (tenant or project based) (not dedicated) ○ Permanent Supportive Housing ○ Public Housing Unit ○ Other permanent housing dedicated for formerly homeless persons ○ Rental by client, with other ongoing housing subsidy LENGTH OF STAY IN PRIOR LIVING SITUATION ○ One night or less ○ One month or more, but less than 90 days ○ Client doesn’t know ○ Two to six nights ○ 90 days or more, but less than one year ○ Client prefers not to answer ○ One week or more, but less than one month ○ One year or longer ○ Data not collected LENGTH OF STAY LESS THAN 7 NIGHTS [TH, PH] ○ No ○ Yes LENGTH OF STAY LESS THAN 90 DAYS [Institutional Housing Situations] ○ No ○ Yes ON THE NIGHT BEFORE – STAYED ON THE STREETS, EMERGENCY SHELTER, SAFE HAVEN [Head of Household and Adults] ○ Yes ○ No Approximate Date This Episode of Homelessness Started ____/____/__________ Number of times the client has been on the streets, ES, or Safe Haven in the last 3 years ○ One Time ○ Client doesn’t know ○ Two Times ○ Client prefers not to answer ○ Three Times ○ Data not collected ○ Four or More Times Total number of months homeless on the streets, ES, or Safe Haven in the last 3 years ○ One month (this time is the first month) ○ Client doesn’t know ○ 2-12 months (specify number of months): ________ ○ Client prefers not to answer ○ More than 12 months ○ Data not collected DISABLING CONDITION [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected PHYSICAL DISABILITY [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite ○ duration and substantially impairs ability to live ○ independently? No ○ Client doesn’t know Yes ○ Client prefers not to answer ○ Data not collected DEVELOPMENTAL DISABILITY [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected CHRONIC HEALTH CONDITION [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected HIV-AIDS [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected MENTAL HEALTH DISORDER [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO MENTAL HEALTH DISORDER – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected SUBSTANCE USE DISORDER [All Clients] ○ No ○ Client doesn’t know ○ Alcohol use disorder ○ Client prefers not to answer ○ Drug use disorder ○ Data not collected ○ Both alcohol and drug use disorders IF “ALCOHOL USE DISORDER” “DRUG USE DISORDER” OR “BOTH ALCOHOL AND DRUG USE DISORDERS” – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected Have you experienced a past or current relationship that was controlling and/or abusive? This includes domestic violence, dating violence, sexual assault, stalking, and human trafficking. [Head of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” When was the last time that you felt unsafe or threatened in a relationship? ○ Within the past three months ○ Client doesn’t know ○ Three to six months ago (excluding six months exactly) ○ Client prefers not to answer ○ Six months to one year ago (excluding one year exactly) ○ Data not collected ○ One year ago or more Are you currently seeking safety from a relationship that is controlling and/or abusive? This includes domestic violence, dating violence, sexual assault, stalking, and human trafficking. ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected INCOME FROM ANY SOURCE [Head of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source Amount ○ Earned Income ○ Temporary Assistance for Needy Families (TANF) ○ Unemployment Insurance ○ General Assistance (GA) ○ Supplemental Security Income (SSI) ○ Retirement income from Social Security ○ Social Security Disability Insurance (SSDI) ○ Pension or retirement income from a former job ○ VA Service-Connected Disability Compensation ○ Child support ○ VA Non-Service-Connected Disability Pension ○ Alimony and other spousal support ○ Private disability insurance ○ Other income source (specify): ○ Worker’s Compensation Total Monthly Income for Individual: RECEIVING NON-CASH BENEFITS [Head of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO NON-CASH BENEFITS – INDICATE ALL SOURCES THAT APPLY ○ Supplemental Nutrition Assistance Program (SNAP) ○ TANF Child Care Services ○ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) ○ TANF Transportation Services ○ Other (specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE [All Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client prefers not to answer ○ Data not collected IF “YES” TO HEALTH INSURANCE – HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health Insurance ○ MEDICARE ○ Health Insurance Obtained Through COBRA ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Health Administration (VHA) ○ State Health Insurance for Adults ○ Other (specify): ○ Indian Health Services Program SEXUAL ORIENTATION [For CoC: YHDP and PSH funded programs – Adults and Head of Household] ○ Heterosexual ○ Other ○ Gay If Other please specify: ○ Lesbian ○ Client doesn’t know ○ Bisexual ○ Client prefers not to answer ○ Questioning/Unsure ○ Data not collected YOUTH EDUCATION STATUS [For CoC: YHDP funded programs – Head of Household] ○ Not currently enrolled in any school or educational course ○ Client doesn’t know ○ Currently enrolled but NOT attending regularly (when school or the course is in session) ○ Client prefers not to answer ○ Currently enrolled and attending regularly (when school or the course is in session) ○ Data not collected IF “NOT CURRENTLY ENROLLED” – MOST RECENT EDUCATIONAL STATUS ○ K12: Graduated from high school ○ Higher education: Pursuing a credential but not currently attending ○ K12: Obtained GED ○ Higher education: Dropped out ○ K12: Dropped out ○ Higher education: Obtaining a credential/degree ○ K12: Suspended ○ Client doesn’t know ○ K12: Expelled ○ Client prefers not to answer ○ Data not collected IF “CURRENTLY ENROLLED” – CURRENT EDUCATIONAL STATUS ○ Pursuing a high school diploma or GED ○ Pursuing other post-secondary credential ○ Pursuing Associate’s Degree ○ Client doesn’t know ○ Pursuing Bachelor’s Degree ○ Client prefers not to answer ○ Pursuing Graduate Degree ○ Data not collected __________________________________________________________________________ Signature of applicant stating all information is true and correct Date