Region 16 Homeless Intake Date: _____/_____/_______ Name: _____________________________________________________ Emergency Contact Information: Name Phone # Address Relationship HUD 40118 ASSESSMENT Are you homeless? YES NO What was the approximate date that your homelessness started? __________________________ How many times have you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ What is the total number of months you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ Is there a disability of a long duration for any family member? YES NO INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Than 3 Months Impairs Ability to Live Independently Documentation of Disability & Severity on File? Receiving Treatment for this disability? Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No What is your current/prior residence? _______________________________________________ How long did you live at the prior/current living situation? _______________________________
Homeless Crisis Response Program Housing Status Documentation Form Applicant Name: _ ____ HMIS ID Number: ________________________________________________________ Staff Member Name: Household without dependent children (complete one form for each adult in the household) Household with dependent children (complete one form for household) Number of persons in the household: _________ This is to certify that the above-named individual or household is currently homeless based on the check mark, other indicated information, and signature indicating their current living situation. Check the appropriate type of documentation used to verify homelessness and attach it to this worksheet. Complete with information on the primary cause of homelessness. Check and complete only one living situation option. Living Situation Type of Eligible Documentation Documentation Attached Persons living on the street or sleeping in a place not designed for or ordinarily used as a regular sleeping accommodation. Signed and dated written certification by person seeking services Signed and dated written certification by an outreach worker Yes No NA Persons living in a shelter designed to provide temporary living arrangements - congregate shelters - transitional housing - hotels/motels paid for by a charitable organization or government program. HMIS shelter/transitional housing record Written referral from previous shelter/transitional housing staff Written referral from charitable organization or government program Yes No NA Persons exiting an institution where they resided for 90 days or less and was residing in a place not meant for human habitation immediately before entering institution. HMIS shelter/transitional housing record Written referral from previous emergency shelter stay Written referral from institution Yes No NA Persons fleeing domestic violence. Written, signed and dated verification from the participant Written, signed and dated verification from the domestic violence service provider Yes No NA