SubCook Initial Intake Assessment Head of Household HMIS ID# Fill-in after ServicePoint Entry Entry Date (Project Start) Date of Engagement (ES/SO) Housing Move-in Date (PH, PSH, RRH) Month / Day / Year Month / Day / Year Month / Day / Year Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client doesn’t know Client refused First Name Middle Name   Last Name Alias/Suffix   SSN Approx. or Partial SSN Reported    Veteran Status Yes No Veteran Status is on the Client Profile Tab and may need to be updated if the client is already in ServicePoint.   Relationship (to HoH) SELF Number in Household: Use a separate HH Member Supplemental page for each additional HH member Date of Birth Approx. or Partial DOB Reported    Gender Male Female Trans Female: M to F Trans Male: F to M Gender Non-Confirming (i.e. not exclusively M or F)   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander NA Primary Language English Spanish Other, Domestic Violence Victim/Survivor Yes No   (If Yes) how long ago was the last incident?  Within the past 3 months  3-6 months ago  6-12 months ago More than a year Client Doesn’t Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Continue to Disability Assessment Client Name:
Disability Assessment Does the client have a disabling condition expected to be of long duration and impedes ability to live independently?  Yes  No  Client doesn’t know  Client Refused Disability Type (If Yes) Start Date Will the Condition be long term? Disability Determination If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Alcohol Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Alcohol and Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Chronic Health Condition Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Developmental Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: HIV/AIDS Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Mental Health Problem Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Physical Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Continue to Chronic Homeless Assessment
Is there a release of information to contact this person? Yes Continue to Household Income Household Income Does the household have any current income?  Yes  No  Client Does Not Know  Client Refused If No, answer the following question and move on to Household Income for AMI Below: Do you need assistance in applying for cash benefits?  Yes  No If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. HH Member Amount Start Date HH Member Amount Start Date Earned Income  Yes No If Yes: $ $ $ $ Unemployment Insurance  Yes No If Yes: $ $ SSI: Supplemental Security Income  Yes No If Yes: $ $ SSDI: Social Security Disability Income  Yes No If Yes: $ $ VA Service Connected Disability Compensation  Yes No If Yes: $ $ Private Disability Insurance  Yes No If Yes: $ $ Worker’s Compensation  Yes No If Yes: $ $ TANF: Temporary Assistance for Needy Families  Yes No If Yes: $ $ General Assistance  Yes No If Yes: $ $ Retirement Income from Social Security  Yes No If Yes: $ $ VA Non-Service Connected Disability Pension  Yes No If Yes: $ $ Pension or retirement income from another job  Yes No If Yes: $ $ Child Support  Yes No If Yes: $ $ Alimony or Other Spousal Support  Yes No If Yes: $ $ Other Source (specify):  Yes No If Yes: $ $
For Each Individual Household Member with income, record their individual total income from all sources below Household Member Total Monthly Income Household Member Total Monthly Income Total Monthly Household Income $_________________ Number of Household Members _______ FY2017 Area Median Income (AMI) Household Size 1 2 3 4 5 6 7 8 15% AMI $742 $848 $954 $1,059 $1,144 $1,229 $1,313 $1,398 30% AMI $1,383 $1,583 $1,779 $1,975 $2,133 $2,292 $2,450 $2,608 50% AMI $2,304 $2,633 $2,963 $3,292 $3,558 $3,821 $4,083 $4,346 80% AMI $3,688 $4,217 $4,742 $5,267 $5,692 $6,113 $6,533 $6,954 100% AMI $4,608 $5,267 $5,925 $6,583 $7,117 $7,642 $8,167 $8,692 Total Monthly Household Income As Percentage Of AMI:  Below 30%  30%-49%  50%-79%  80%-99%  100% and above 50% and Above Illinois RIN# Optional (Illinois Recipient Identification Number for Non-Cash Benefits and Health Insurance) Non-Cash Benefits Does the household currently receive any Non-Cash Benefits?  Yes  No  Client Does Not Know  Client Refused If No - Do you need assistance in applying for non-cash benefits?  Yes  No Please indicate which of the following non-cash benefits have you received over the last 30 days. (You may use “All” if all household members receive the benefit) Start Date Amount (optional) Supplemental Nutrition Assistance Program (Food Stamps)  Yes No If Yes, Household Members: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)  Yes No If Yes, Household Members: TANF child care services  Yes No If Yes, Household Members: TANF transportation services  Yes No If Yes, Household Members: Other TANF-Funded Services  Yes No If Yes, Household Members: Other Source (specify):  Yes No If Yes, Household Members:
Covered by Health Insurance Do household members currently have health insurance?  Yes  No  Client Does Not Know  Client Refused If No - Do you need assistance in applying for Health Insurance?  Yes  No Continue to the MCO question and Health Insurance Sub-Assessment Medicaid MCO or Health Insurance Provider:  Aetna  Blue Cross (BCBSIL)  Cigna  County Care  Harmony  Humana  Illinicare  Meridian  Molina  NextLevel  Out of State  United  Not Applicable (N/A) Complete the following (You may use “All” if all household members receive the benefit) Start Date Medicaid  Yes No If Yes, Household Members: Medicare  Yes No If Yes, Household Members: Illinois All Kids (State Children’s Health Insurance Program)  Yes No If Yes, Household Members: Veteran’s Administration Medical Services  Yes No If Yes, Household Members: Employer Provided Health Insurance  Yes No If Yes, Household Members: Health Insurance obtained through COBRA  Yes No If Yes, Household Members: Private Pay Health Insurance  Yes No If Yes, Household Members: State Health Insurance for Adults  Yes No If Yes, Household Members: Indian Health Services Program  Yes No If Yes, Household Members: Other  Yes If Yes, Household Members: If “Yes” to Other, Specify Source: end of health insurance questions Do you have a case worker with the Illinois Department of Child and Family Services (DCFS)? If yes, you might be eligible for housing assistance through DCFS.  Yes  No  Not Applicable Have you ever been involved in the child welfare system?  Yes  No  Not Applicable
No Alternative Housing Options  Required  Required  Required Can Case Manager Vouch Client Has Good Moral Character  Required Proof that client has worked in State of Illinois  Required Previous Benefit  No ESG assistance in last 36 months  No ESG assistance in last 36 months  No IDHS HP assistance in previous 2 years Head of Household Name: Initial Intake Assessment HH Member Supplemental HMIS ID# Fill-in after ServicePoint Entry Entry Date (Project Start) Month / Day / Year Name of Household Member (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not know Client refused First Name Middle Name   Last Name Alias/Suffix   SSN Approx. or Partial SSN Reported    Veteran Status Yes No Veteran Status is on the Client Profile Tab and may need to be updated if the client is already in ServicePoint.   Relationship (to HoH) HoH’s Child HoH’s Spouse/Partner HoH’s Other Relation Other: Non-Relation NA NA Date of Birth Approx. or Partial DOB Reported    Gender Male Female Trans Female: M to F Trans Male: F to M Gender Non-Confirming (i.e. not exclusively M or F)   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander Other   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander Other NA Primary Language English Spanish Other,
Physical Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Do you have a case worker with the Illinois Department of Child and Family Services (DCFS)?  Yes  No  Not Applicable Have you ever been involved in the child welfare system?  Yes  No  Not Applicable If Yes, did you age out of the foster care system?  Yes  No  Not Applicable This means you were in foster care when you became of age (18-21), you were not adopted and you were not reunified with family. Instead you were recognized as an adult and freed from the foster care system.