All Applicants Must Sign Below By signing below I attest that the information I have provided for eligibility and intake is a true and accurate account of the current situation, income and household. Client signature: _______________________________________________________ Date: ___________________ Agency Representative Name (print): ______________________________________ Agency Representative Signature: _________________________________________ Date: ___________________ (This Page Left Blank On Purpose) Head of Household Name: Universal Intake HH Member Supplemental HMIS ID# Fill-in after ServicePoint Entry Intake/Entry Date 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 Transgender: M to F Transgender: F to M Doesn’t identify as male, female or transgender   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American Native Hawaiian or Pacific Islander   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian American White Native Hawaiian or Other Pacific Islander NA NA Primary Language English Spanish Other, specify: 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 ago  Client Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Refused Disabling Conditions: Yes No   Continue to Disability Assessment Client Name: Disability Assessment Disability Type (If Yes) Date Currently receiving Services or Treatment? Will the Condition be long term? Disability Determination Documentation of disability and severity on file Alcohol Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes: Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes: Alcohol and Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Know Client Refused Notes: Chronic Health Condition Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Doesn’t Know Refused Yes No Yes No Doesn’t Know Refused Yes No If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Yes No Client Doesn’t Know Client Refused Notes: