Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION 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 ○ HIV-AIDS Clients] No Client doesn’t 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 CONDITION 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 and drug abuse ○ ○ Client doesn’t know ○ Alcohol abuse ○ Client refused ○ Drug abuse Data not collected ○ ○ IF 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 Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ INCOME FROM ANY SOURCE of Household and Adults] No Client know ○ ○ Yes Client refused ○ ○ Data not collected ○ IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY “YES” – Income Source Amount Income Source Alimony and other spousal support Child support ○ ○ Pension or retirement income from former job Earned Income ○ ○ Retirement Income from Social Security General Assistance (GA) ○ ○
○ 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 abuse ○ Data not collected IF “ALCOHOL “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 ○ Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source ○ Alimony and other spousal support ○ Child support ○ Pension or retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA)
PATH-Project-Intake-HMIS-2017-rev14Sept17.docx