CT HMIS Runaway Homeless Youth Family Discharge Form Applicant (Head of Household) Information: First Name: ___________________________ Last Name: __________________________ Client ID#: ____________________ Project End Date: _____________________ Case Manager Assigned to Discharge: _____________________ Project Completion Status: Completed Project Youth voluntarily left early Youth was expelled or otherwise involuntarily discharged from project Household Member Name Date of Birth Gender Relationship to Head of Household HMIS ID# Self Destination Type: Emergency shelter or hotel paid w/ voucher Transitional housing for homeless persons (Including homeless youth) Permanent housing (other than RRH) for 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: ___________________________________________
Health Insurance (All clients): Head of Household (HOH) Member 2 Member 3 Member 4 Member 5 MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ____________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________