○ Moved to a transitional or temporary housing facility or program ○ Data not collected IF “ABLE TO MAINTAIN HOUSING AT PROJECT TO HOUSING ASSESSMENT Subsidy Information ○ Without a subsidy ○ With an subsidy acquired since project entry ○ With the subsidy they had at project entry ○ Only with financial assistance other than a subsidy IF “MOVED TO NEW HOUSING UNIT” TO HOUSING ASSESSMENT Subsidy Information ○ With subsidy ○ Without an subsidy IN PERMANENT HOUSING Housing Projects, for Heads of Households] ○ No ○ Yes IF “YES” TO PERMANENT HOUSING Housing Move-in Date ____/____/__________ DISABLING CONDITION Clients – if ‘yes’ to any condition, mark ‘yes’ ] ○ No ○ Client doesn’t 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected
IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT Income Source Amount Income Source Amount ○ Alimony and Other 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 Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension (specify): Total 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 ○ Other (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health Insurance ○ MEDICARE ○ Insurance Obtained through COBRA ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ Other (specify) ○ Indian Health Services Program Pikes Peak CoC Entry Questions Reasons or Contributing Factors to Homelessness ○ Abuse or Violence in My Home ○ Lost a Job Could Not Find Work ○ Alcohol Substance Abuse Problems ○ Medical Expenses ○ Asked to Leave ○ Mental Illness ○ Bad Credit ○ to Find Work ○ Not Pay Utilities ○ Problems with Public Benefits ○ Discharge from Foster Care ○ Reasons Related to My Sexual Orientation ○ Discharged from Jail ○ Relationship Problems or Family