Head of Household (HOH) Member 2 Member 3 Member 4 Member 5 MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ____________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ Income Income received from any source (HOH and Adults only)? No Yes Client doesn’t know Client refused Data Not Collected *Note: Income received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. Head of Household HH Member 1 HH Member 2 HH Member 3 Income Type Monthly Amount Monthly Amount Monthly Amount Monthly Amount Unemployment Insurance N Y $ N Y $ N Y $ N Y $
Tamil Javanese Korean Turkish Telugu Marathi Italian Thai Burmese Kannada Gujarati Polish Hindi Cantonese Haitian Creole Unknown Other: ___________________________________________ Religion: Protestant Catholic Jewish Muslim Buddhist Mormon Orthodox Christian Hindu Pentecostal None Other Unknown *Marital Status: Never Married Married Separated Divorced/Annulled Widowed Civil Union Other Unknown *Primary Referral Source: Self Family/Friend Mental Health Provider Substance Abuse Provider Medical Health Practitioner School Employer/Supervisor Employee Assistance Program Clergy/Church/Synagogue Dept. of Children and Families Dept. of Social Services Dept. of Developmental Disabilities Community Referral Order Probation/Parole Police Shelter Dept. of Corrections Other Unknown *Pregnancy Status: No Yes Client Doesn't Know Client Refused Data Not Collected Tobacco: Yes No Unknown
Co-Occurring Assessment Date: ___________________________ *Mental Health Screening Used: Nothing Mental Health Screen Form III Modified Mini Declined Medically or Clinically Inappropriate *Substance Abuse Screening Used: SSI Alcohol and Drugs CAGE- Adapted to Include Drugs Declined Medically or Clinically Inappropriate * Employment Status: Employed full time (in competitive employment) Employed part time (in competitive employment) Unemployed (looking for work in the past 30 days, or on a layoff) Paid but non-competitive work (transitional employment programs) Paid but non-competitive work (work inside the clubhouse or treatment agency, mobile work crews and consumer-run businesses) Not in Labor Force: student enrolled in a school or job-training program Not in Labor Force: homemaker Not in Labor Force: retired Not in Labor Force: SSI SSDI Not in Labor Force: Inmate of institution. Not in Labor Force: other reason Other Unknown *Highest Grade Completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Unknown Persons Dependent on Income: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Minors Dependent on Income: 1 2 3 4 5