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?  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 Client Location
HOMELESSNESS PREVENTION/ RAPID RE-HOUSING - Eligibility Checklist Select the situation(s) that caused you to need assistance. All hardships must be documented and verified.  Loss of income/job  Natural Disaster/Fire  Car Repair  Funeral Expenses  Medical Expenses  Displacement by Gov.  Condemnation  Foreclosure  Release from institution  Loss of hours at work  Other Applicable __________________________________  Homeless Describe Current Crisis/Need for Assistance/Housing Situation: Is the household unable to identify appropriate subsequent housing options; AND do they lack the financial resources and support networks needed to obtain immediate housing or remain in existing housing? Is the household unable to relocate with another family member or friends? Does the household lack sufficient savings or other assets that can be used to pay rent, arrearages and other housing costs? (Must provide statements for any bank accounts) If No, Total savings/assets: Eligibility Criteria by Program Type ESG Prevention ESG Rapid Re-housing READE Prevention IDHS Prevention Housing Status at Risk of becoming homeless Homeless in suburban Cook County 2 weeks or more at Risk of becoming homeless Current or Last Permanent Address suburban Cook County for at least 1 month suburban Cook County within last six months South region of suburban Cook County Illinois Income 30% AMI no income restriction at initial intake - Below 30% AMI at redetermination only sufficient to cover rent Evidence of Hardship Required Required Required 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 ESG assistance in last 36 months ESG assistance in last 36 months 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 Head of Household (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, Yes No  
Domestic Violence Victim/Survivor (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?  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: 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: 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: 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: 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: