HIV-AIDS Clients] No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO HIV-AIDS SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ MENTAL HEALTH PROBLEM Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO MENTAL HEALTH PROBLEMS SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently Yes ○ Data not collected ○ SUBSTANCE ABUSE PROBLEM Clients] No Both alcohol & drug ○ ○ Client know ○ Alcohol abuse ○ Client refused ○ Drug abuse Data not collected ○ ○ IF ABUSE” ABUSE” OR ALCOHOL AND DRUG ABUSE”– SPECIFY “ALCOHOL “DRUG “BOTH No Client doesn’t know Expected to be of long-continued and indefinite duration and ○ ○ substantially impairs ability to live independently? Yes Client refused ○ ○ DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DOMESTIC VIOLENCE “YES” WHEN EXPERIENCE OCCURRED One year ago or more Within the past months ○ ○ Client doesn’t know ○ to six months ago (excluding six months exactly) ○ Client refused ○ Data not collected Six months to one year ago (excluding one year exactly) ○ ○ No Client doesn’t know ○ ○ ARE YOU CURRENTLY FLEEING? Client refused ○ Yes ○ Data not collected ○ INCOME FROM ANY SOURCE of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ 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 PROBLEMS – 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 & drug ○ Alcohol abuse ○ Client know ○ Client refused ○ Drug abuse ○ 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 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 months ○ One year ago or more ○ 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