○ Yes ○ Client refused ○ Data not collected Theater of Operations: Iraq (Operation Iraqi Freedom) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: Iraq (Operation New Dawn) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Theater of Operations: operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected Branch of the Military ○ Army ○ Coast Guard ○ Air Force ○ Client know ○ Navy ○ Client refused ○ Marines ○ Data not collected Discharge Status ○ Honorable ○ Dishonorable ○ General honorable conditions ○ Uncharacterized ○ Other than honorable conditions (OTH) ○ Client doesn’t know ○ Client refused ○ Bad Conduct ○ Data not collected RELATIONSHIP TO HEAD OF HOUSEHOLD Client Households] ○ Self ○ Head of household - other relation to ○ Head of household’s ○ Head of household’s spouse or partner ○ Other: member CLIENT LOCATION [only if multiple CoC’s] ______________________ ZIP CODE OF LAST PERMANENT ADDRESS Clients] WHEN CLIENT WAS ENGAGED Outreach Only] Date of Engagement: ____/____/__________ IN PERMANENT HOUSING [Permanent 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 hotel/motel 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 ○ Hospital or 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 ○ 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 ○ Owned by client, with ongoing housing subsidy ○ Substance abuse treatment facility detox center ○ Permanent housing (other than RRH) for formerly homeless persons ○ Transitional housing for homeless persons (including homeless ○ 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 Times ○ Client refused ○ Three Times ○ Data not collected ○ Four or More Times 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 know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY Clients] ○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY Clients] ○ 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 ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ No ○ Client 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS Clients] ○ No ○ Client 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 Clients] ○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected SUBSTANCE PROBLEM Clients] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client know ○ Client refused ○ Drug ○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] ○ No ○ Client doesn’t ○ 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 ○ Yes ○ Client refused ○ Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source
○ Alimony and Spousal Support ○ Child support ○ Pension or Retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA) ○ Social Security Disability Insurance (SSDI) ○ Private Disability Insurance ○ Supplemental Security Income (SSI) ○ Unemployment Insurance ○ TANF (Temporary Assist for Needy Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Specify Other” monthly amount: RECEIVING BENEFITS​ of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO BENEFITS – INDICATE ALL SOURCES THAT APPLY ○ Supplemental Nutrition Assistance Program (SNAP) ○ TANF Childcare Services ○ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) ○ TANF Transportation Services ○ (Specify): ○ TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health ○ MEDICARE ○ Insurance Obtained through ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ Health Insurance for Adults ○ Other (specify): ○ Indian Health Services Program PRIMARY LANGUAGE Clients, optional] ○ English ○ Mandarin ○ Spanish ○ Tagalog ○ Vietnamese ○ Other ○ Unknown Signature of applicant stating all information is true and correct Date