Persons Dependent on Income: 1 6 11 2 7 12 3 8 13 4 9 14 5 10 15 Minors Dependent on Income: 1 6 11 2 7 12 3 8 13 4 9 14 5 10 15 *Principle Income Source: Disability Public Assistance Unknown None Retirement Other Salary *Living situation at time of episodic assessment: Private residence, client owns or holds lease Residential Care Home/ Board and Care Psychiatric/SA/Medical Inpatient. Private residence, friend or relative owns the Congregate residential care (24-hour supervision, Correctional Facility residence or holds lease group setting, services focus on MH, SA, &/or MR Homeless Shelter, Single Room Occupancy (Hotel, YMCA, Rooming issues, Recovery House.) Homeless (including on street), House) Crisis / Respite Bed Other, Private residence, Community agency owns or holds Skilled Nursing Facility/Intermediate Care Facility Unknown lease /Nursing Home Was Client Homeless in Last Six Months: Yes No Unknown Number of Days in the Last 30 that the client lived in a Controlled Environment? (0 – 30) _______ Enter a value between 0 and 30 to represent the number of days in a controlled environment *Number of arrests in last 30 days: (0 – 30) ____________ Enter a value between 0 and 30 to represent the number of arrests; if unknown then write in Unknown *Number of Self-Help programs/meetings in last 30 days: (0 – 90) ____________ Enter a value between 0 and 90 to represent the number of arrests; if unknown then write in 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 6 7 8 9 10 11 12 13 14 15 *Principle Income Source: Disability None Other Public Assistance Retirement Salary Unknown *Living situation at time of episodic assessment: Private residence, client owns or holds lease Private residence, friend or relative owns the residence or holds lease Single Room Occupancy (Hotel, YMCA, Rooming House) Private residence, Community agency owns or holds lease Residential Care Home/ Board and Care Congregate residential care (24-hour supervision, group setting, services focus on MH, SA, &/or MR issues, Recovery House.) Crisis / Respite Bed Skilled Nursing Facility/Intermediate Care Facility /Nursing Home Psychiatric/SA/Medical Inpatient. Correctional Facility Homeless Shelter, Homeless (including on street), Other, Unknown Was Client Homeless in Last Six Months: Yes No Unknown Number of Days in the Last 30 that the client lived in a Controlled Environment? (0 – 30) _______ Enter a value between 0 and 30 to represent the number of days in a controlled environment *Number of arrests in last 30 days: (0 – 30) ____________ Enter a value between 0 and 30 to represent the number of arrests; if unknown then write in Unknown *Number of Self-Help programs/meetings in last 30 days: (0 – 90) ____________ Enter a value between 0 and 90 to represent the number of arrests; if unknown then write in Unknown
HMIS%2BPATH%2BFamily%2BDischarge%2BForm%2B-%2B7.2.docx