CLARITY HMIS: VA SERVICES INTAKE FORM (HUD VASH, SSVF, GPD) Use block letters for text and bubble in the appropriate circles. Please complete a separate form for each household member. PROJECT START DATE​ Clients] Day Year SOCIAL SECURITY NUMBER​ Clients] QUALITY OF SOCIAL SECURITY ○ Full SSN reported ○ Client doesn’t know ○ Client refused ○ Approximate or partial SSN reported ○ Data not collected CURRENT NAME Clients] N/A Last Middle Suffix QUALITY OF CURRENT NAME ○ Full name reported ○ Client doesn’t know ○ Partial, street name, or code name reported ○ Client refused ○ Data not collected DATE OF Clients] Age: Month Day Year QUALITY OF DATE OF BIRTH ○ Full DOB reported ○ Client doesn’t know ○ Approximate or partial DOB reported ○ Client refused ○ Data not collected GENDER​ Clients] ○ Female ○ Client doesn’t know [All [All
○ Male ○ Client refused ○ Female (MTF or Male to Female) ○ Data not collected ○ Trans Male (FTM or Female to Male) ○ Gender Non-Conforming (i.e. not exclusively male or female) RACE all applicable) Clients] American Indian or Alaskan Native ○ Client does not know Asian ○ Client refused Black/African American ○ Data Not Collected Hawaiian or Pacific Islander White/Caucasian ETHNICITY​ Clients] ○ ○ Client does not know ○ Client refused ○ Hispanic/Latino ○ Data Not Collected ○ Other VETERAN STATUS​ Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO VETERAN STATUS Year entered military service (year) Year separated from military service (year) Theater of Operations: World War II ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Korean War ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Vietnam War ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Persian Gulf War (Desert Storm) ○ No ○ Client doesn’t know ○ Yes ○ Client refused
IN PERMANENT HOUSING Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-in Date ____/____/__________ LIVING SITUATION TYPE OF RESIDENCE [Head of Household and Adults ] ○ Emergency shelter, including paid for w/ voucher ○ Rental by client, no ongoing housing subsidy ○ Foster care home or foster care group home ○ Rental by client, with GPD TIP subsidy ○ Hospital or other residential medical facility ○ Rental by client, with VASH subsidy ○ Hotel or motel paid for without emergency shelter voucher ○ Rental by client, with other ongoing housing subsidy ○ Interim Housing ○ Residential project or halfway house with no homeless criteria ○ Jail, prison or juvenile detention facility ○ Safe Haven ○ Long-term care facility or nursing home ○ Staying or living in a family member’s room, apartment or house ○ Owned by client, no housing subsidy ○ Staying or living in a friend’s room, apartment or house ○ Owned by client, with ongoing housing subsidy ○ Substance abuse treatment facility or detox center ○ Permanent housing (other than RRH) for formerly homeless persons ○ Transitional housing for homeless persons (including homeless youth) ○ Place not meant for habitation ○ Client doesn’t know ○ Client refused ○ Psychiatric hospital or other psychiatric facility ○ Data not collected LENGTH OF STAY IN PRIOR LIVING SITUATION ○ One night or less ○ One month or more, but less than 90 days ○ Client doesn’t know ○ Two to six nights ○ 90 days or more, but less than one year ○ Client refused ○ One week or more, but less than one month ○ One year or longer ○ Data not collected LENGTH OF STAY LESS THAN 7 NIGHTS [TH, PH] ○ No ○ Yes
LENGTH OF STAY LESS THAN 90 DAYS [If type of stay is Interim Housing- Facility /Institution etc] ○ No ○ Yes ON THE NIGHT BEFORE - DID YOU STAY - STREETS, IN EMERGENCY SHELTER, SAFE HAVEN [Head of Household and Adults] ○ Yes ○ No Approximate Date Homelessness Started ____/____/__________ Number of times the client has been on the streets, ES, or Safe Haven in the last 3 years ○ One Time ○ Client doesn’t know ○ Two ○ Client refused ○ Three Times ○ Data not collected ○ Four or More Times Total Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years ○ One month (this time is the first month) ○ Client doesn’t know ○ months (specify number of months): ________ ○ Client refused ○ More than 12 months ○ Data not collected DISABLING CONDITION Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client know ○ Client refused
○ Data not collected CHRONIC HEALTH CONDITION required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HIV-AIDS – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected MENTAL HEALTH PROBLEM required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO MENTAL HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected SUBSTANCE ABUSE PROBLEM required for SSVF] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug abuse ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults, not required for SSVF] ○ No ○ Client doesn’t know
○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED ○ Within the past months ○ One year ago or more ○ Three to six months ago (excluding six months exactly) ○ Client doesn’t know ○ Client refused ○ Six months to one year ago (excluding one year exactly) ○ Data not collected Are you currently fleeing? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected HOUSEHOLD INCOME AS A PERCENTAGE OF AMI of Household, not required for HUD VASH or GPD] ○ Less than 30% ○ Greater than 50% ○ 30% to 50% CONNECTION WITH SOAR of Households and Adults, not required for HUD VASH or GPD] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected LAST GRADE COMPLETED of Household & Adults,not required for GPD] ○ Less than 5 ○ Grades 5-6 ○ Grades 7-8 ○ Grades 9-11 ○ Grade 12 ○ School does not have grade levels ○ GED ○ Some college ○ Associate’s Degree ○ Bachelor's degree ○ Graduate Degree ○ Vocational certification ○ Client doesn't know ○ Data not collected ○ Client refused EMPLOYMENT STATUS of Household, Adults, HUD-VASH OTH and SSVF] Employed ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected If “Yes” for employed – Type of employment ○ [Head