DOH AIDS/HOPWA Individual Discharge Form Applicant (Head of Household) Information: First Name: ___________________________ Last Name: __________________________ Client ID#: ____________________ Project Exit Date: _____________________ Case Manager Assigned to Discharge: _____________________ Destination Type: Emergency shelter or hotel paid w/ voucher Transitional housing for homeless persons (including homeless youth) Permanent housing (there than RRH) for formerly homeless persons Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric) Jail, prison, or juvenile detention facility Rental, no subsidy Owned, no subsidy With family, temporary tenure With friends, temporary tenure Hotel / motel w/o emergency voucher Foster care or foster care group home Place not meant for human habitation Safe Haven Rental, VASH subsidy Rental, (non-VASH) housing subsidy Owned, with subsidy With family, permanent tenure With friends, permanent tenure Deceased Long-term care facility or nursing Home Moved from one HOPWA funded project to HOPWA PH Moved from one HOPWA funded project to HOPWA TH Rental by client, with GPD TIP housing subsidy Residential project or halfway house with no homeless criteria No Exit Interview completed Client doesn't know Client refused Other If Other, please explain: ___________________________________________
Housing Assessment at Exit: Able to maintain the housing they had at project entry Moved to new housing unit Moved in with family/friends on a temporary basis Moved in with family/friends on a permanent basis Moved to a transitional or temporary housing facility or program Client became homeless – moving to a shelter or other place unfit for human habitation Client went to jail/prison Client doesn’t know Client refused Client died Data not collected Non-Cash Benefit from any source? No Yes Client doesn’t know Client refused Data Not Collected Non-cash benefits received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. Non- Cash Benefits List YES / NO (SNAP) Food Stamps Special Supplemental Nutrition Program for WIC TANF Child Care Services TANF Transportation Other TANF Funded Services Client Doesn't know Client Refused Other (Please Specify): Covered by Health Insurance: No Yes Client doesn’t know Client refused Data Not Collected
Health Insurance: Type of Insurance Head of Household YES / NO IF NO (*Note: This is NOT Required except for HOPWA Programs) Medicaid / HUSKY A, C, D applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Medicare applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused State Children’s Health Insurance Program – HUSKY B applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Veterans Administration (VA) Medical Services applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Employer-Provided Health Insurance applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Health Insurance Obtained through COBRA applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Private Pay Health Insurance applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Indian Health Services Program applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused State Health Insurance for Adults applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Other (specify): ____________________________ applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused