Universal Intake Form Head of Household HMIS ID# Fill-in after ServicePoint Entry Date Month / Day / Year Client doesn’t Client Name of Head of Household middle, last name, suffix (e.g., Jr, Sr, III)) know refused First Name Middle Name   Last Name Alias/Suffix   Approx. or Partial SSN    SSN Reported Veteran Status is on the Client Profile Tab and may need to be updated Yes No   Veteran Status if the client is already in ServicePoint. Relationship Use a separate HH Member Supplemental page SELF Number in Household: (to HoH) for each additional HH member Approx. or Partial Date of Birth    DOB Reported Male Transgender: M to F Doesn’t identify as male, Gender   Transgender: F to M female or transgender Female Ethnicity   Non-Hispanic/Latino Hispanic/Latino American Indian or Native Hawaiian or Black/African American Alaskan Native Pacific Islander Primary Race   White Asian American Indian or Black/African American Native Hawaiian or Other Secondary Alaskan Native Pacific Islander Race (Leave NA NA Blank if None) Other Primary English Spanish Other, specify: Language   Yes No (If Yes) how long ago was the last incident? Domestic Within the past 3 months 3-6 months ago 6-12 months ago    Violence More than a year ago Client Doesn’t Know Client Refused    Victim/Survivor (If Yes) are you currently fleeing? Yes No Client Does Not Know Client Refused     Disabling   Yes No Conditions: Continue to Disability Assessment
Universal Intake Form Head of Household HMIS ID# Fill-in after ServicePoint Entry Date Month / Day / Year Name of Head of Household middle, last name, suffix (e.g., Jr, Sr, III)) Client doesn’t know Client refused First Name Middle Name   Last Name Alias/Suffix   SSN Approx. or Partial SSN Reported    Veteran Status Yes No Veteran Status is on the Client Profile Tab and may need to be updated if the client is already in ServicePoint.   Relationship (to HoH) SELF Number in Household: Use a separate HH Member Supplemental page for each additional HH member Date of Birth Approx. or Partial DOB Reported    Gender Male Female Transgender: M to F Transgender: F to M Doesn’t identify as male, female or transgender   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Pacific Islander   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Black/African American Native Hawaiian or Other Pacific Islander Other NA NA Primary Language English Spanish Other, specify: Domestic Violence Victim/Survivor Yes No   (If Yes) how long ago was the last incident?  Within the past 3 months  3-6 months ago  6-12 months ago  More than a year ago  Client Doesn’t Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Refused Disabling Conditions: Yes No   Continue to Disability Assessment