Please explain connections: Please note if you have a need or a preference for each of the following. Need Preferred Notes Cultural or population specific housing (tribal, HIV/AIDS, LBGT) Site GRH Have a Front Desk Mobility/Access Access to public transportation Safety Scattered Site Stay enrolled in same school district Sober Housing/Treatment based Contact Information: Contact Name Relationship Phone Email Notes Current Case Workers/Providers that you are working with: PROVIDER TYPE AGENCY WORKER EMAIL PHONE NOTES Opening Script my name is [interviewer name] and I work for [organization name]. To determine your eligibility for homeless services, I would like to assess your housing and service needs. If you give me permission, I will ask you questions about your health and housing. The assessment will take about 15 minutes. Some of the questions will ask personal questions, but only require yes or no answers. The questions are not intended to judge you, but to assess your current needs and eligibility for services. If you ask, I can clarify or you can decide not to answer a question. If you do not answer a question, no one will be upset with you. However, this information is important to help determine if you qualify for services. Skipped or inaccurate answers may affect your eligibility. It will benefit you to answer as honestly as possible, especially since we may need to verify some of your answers later.
Have you ever had to leave an apartment, shelter program, or other place you were staying because of your physical health? Yes No Refused Do you have any chronic health issues with your liver, kidneys, stomach, lungs or heart? Yes No Refused If there was space available in a program that specifically assists people that live with HIV or AIDS, would that be of interest to you? Yes No Refused Do you have any physical disabilities that would limit the type of housing you could access, or would make it hard to live independently because you’d need help? Yes No Refused When you are sick or not feeling well, do you avoid getting help? Yes No Refused Are you currently pregnant, have you ever been pregnant, or have you ever gotten someone pregnant? Yes No Refused If “yes” to any of the above, SCORE 1 for Physical Health SCORE Has your drinking or drug use led you to being *kicked out of an* apartment or program where you were staying in the past? * “asked or forces to leave” Yes No Refused Will drinking or drug use make it difficult for you to stay housed or afford your housing? Yes No Refused If you’ve ever used marijuana, did you ever try is at age 12 or younger? *Did you ever use marijuana at age 12 or younger? Yes No Refused If “yes” to any of the above, then SCORE 1 for Substance Use. SCORE Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of: A mental health or concern? Yes No Refused A past head injury? Yes No Refused A learning disability, developmental disability, or other impairment? Yes No Refused Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need help? Yes No Refused If yes to any of the above, then SCORE 1 for Mental Health SCORE If the respondent scored 1 for Physical Health AND 1 for Substance Use AND 1