○ 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 HIV-AIDS Clients] ○ 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 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 ABUSE PROBLEM Clients] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – SPECIFY ○ No ○ Client doesn’t know
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ Yes ○ Client refused ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED ○ Within the past three 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 INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY 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 Needy Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Specify Other” 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 Infants, and Children (WIC) ○ TANF Transportation Services ○ Other (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients]
○ No ○ Client doesn’t 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 ○ Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ (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 ○ Moved to Find Work ○ Could Not Pay Utilities ○ Problems with Public Benefits ○ Discharge from Foster Care ○ Reasons Related to My Sexual Orientation ○ Discharged from Jail ○ Relationship Problems or Family Break-up ○ Discharged from Prison ○ Unable to Pay Rent Mortgage ○ Does Not Apply to Me ○ Client doesn't know ○ Family Member or Personal Illness ○ Client refused ○ Legal Problems ○ Other Did you relocate to Colorado/Colorado Springs? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected If yes, why (select all that apply)? ○ Care of sick relative ○ Family Support ○ Climate ○ Medical Needs ○ Colorado marijuana laws ○ Natural Disaster ○ Driver's Licenses/Identification Cards for Immigrants ○ Needed services ○ Employment ○ Domestic Violence Signature of applicant stating all information is true and correct Date