Two Times Client refused ○ ○ Three Times Data not collected ○ ○ Four or More Times ○ Total Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years One (this time is the first month) Client doesn’t know ○ ○ months (specify number of months): ________ Client refused ○ ○ More than 12 months Data not collected ○ ○ WHEN CLIENT WAS ENGAGED Date of Engagement: ____/____/__________ PATH STATUS No ○ Client Became Enrolled in PATH Yes ○ Date of Status Determination ____/____/__________ IF TO ENROLLED IN PATH “NO” Client was found ineligible for PATH ○ Reason Not Enrolled Client was not enrolled for other reason(s) ○ DISABLING CONDITION Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ PHYSICAL DISABILITY Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO PHYSICAL DISABILITY 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 ○ DEVELOPMENTAL DISABILITY Clients] No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DEVELOPMENTAL DISABILITY SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently Client refused ○ Yes ○ Data not collected ○ CHRONIC HEALTH CONDITION Clients] No Client know ○ ○
○ Two Times ○ Client refused ○ Three Times ○ Data not collected ○ Four or More Times Total Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years ○ One (this time is the first month) ○ Client doesn’t know ○ months (specify number of months): ________ ○ Client refused ○ More than 12 months ○ Data not collected WHEN CLIENT WAS ENGAGED Date of Engagement: ____/____/__________ PATH STATUS Client Became Enrolled in PATH ○ No ○ Yes Date of Status Determination ____/____/__________ IF “NO” TO ENROLLED IN PATH Reason Not Enrolled ○ Client was found ineligible for PATH ○ Client was not enrolled for other reason(s) DISABLING CONDITION Clients] ○ 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 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 know
PATH-Project-Intake-HMIS-2017-rev14Sept17.docx