INTAKE / HMIS ENTRY FORM for homeless projects CONDITION 1 MET CONDITION 2 MET CONDITION 3 MET PROJECT START DATE  Information provided by the client or from the referral indicates they are eligible  Client as indicated they want to be housed in the project  Client is approved to access services/housing through the project / / HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix) EXISTING HOUSEHOLD INFO This form is adding client(s) to an existing household Yes No If yes, HMIS Client ID (HoH) ____________ SSN (HoH) DATE OF BIRTH COC LOCATION CODE COUNTY WHERE SERVED  BOS OH-507 Other ____________ VETERAN STATUS (HoH) ETHNICITY (HoH) GENDER (HoH)  Did Not Serve Active Duty in the US Military  Non-Hispanic/Latino  Male  Transgender female to male (Transgender man) Served Active Duty in the US Military  Hispanic / Latino  Female  Transgender male to female (Transgender woman)  Gender Non-Conforming PRIMARY RACE (HoH) All That Apply  American Indian or Alaskan Native (AI/AN)  / African American (B)  Native / Hawaiian/Other Pacific Islander (NH)  Asian (A)  White (W)  Client refused  Client doesn’t know PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS: NAME SOCIAL SECURITY NUMBER DOB Relationship to HEAD OF HOUSEHOLD RACE(s) (choose from the selection above) (Y/N) Gender Veteran (Y/N) INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Than 3 Months & Impairs Ability to Live Independently Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No
1 2 3 4 or more 1 2 3 4 5 6 7 8 9 10 11 12 or more ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING CASH INCOME FROM AND SOURCE?  YES  NO Source Amount Recipient(s) Source Amount Recipient(s)  Alimony or spousal support $ Social Security Income (SSI) $ Cash assistance/TANF $ Social Sec Disability Income (SSDI) $ Child support $ Unemployment $ Earned Income $ VA Service Connected Disability $ Pension from a former job $ Veteran's Pension $ Retirement from Social Security $ Worker’s Compensation $ Private Disability Insurance $ General Assistance $ Sources? Source___________________ $ Other Sources? Source_________________ $ TOTAL MONTHLY INCOME (record separately for each adult) $ TOTAL MONTHLY INCOME (record separately for each adult) $ * income for a goes under the adult receiving it* ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING NON CASH INCOME?  YES  NO Source Recipient(s) Source Recipient(s)  Food Stamps - Amount $  TANF care services  WIC  TANF transportation services  Other: _____________________  Other TANF-funded services ANYONE IN THE HOUSEHOLD RECEIVING HEALTH INSURANCE?  YES  NO Source Recipient(s) Source Recipient(s)  Medicaid Employer-provided Health Insurance Medicare Health insurance obtained through COBRA State Children’s Health Insurance Program (SCHIP) Private Pay Health Insurance Veteran’s Administration (VA) Medical Services Health Insurance for Adults Indian Health Services Program RRH & PSH ONLY - HOUSING MOVE-IN DATE (Normally not known at Entry): Move-In Date (Month/Day/Year) : / / ADULTS AFFECTED BY DOMESTIC VIOLENCE  YES  NO NAME EXTENT OF DOMESTIC VIOLENCE  Within past 3 months Within the past 6-12 months  Within the past 3-6 months More than 1 year ago Currently Fleeing? YesNo NAME EXTENT OF DOMESTIC VIOLENCE  Within past 3 months Within the past 6-12 months  Within the past 3-6 months  More than 1 year ago Currently Fleeing? YesNo