DOH AIDS/HOPWA Individual Discharge Form Applicant (Head of Household) Information: First Name: ___________________________ Last Name: __________________________ Client ID#: ____________________ Project Exit Date: Case Manager Assigned to Discharge: _____________________ _____________________ Destination Type: With family, temporary tenure With friends, permanent tenure Emergency shelter or hotel paid w/ voucher With friends, temporary tenure Deceased Transitional housing for homeless persons (including homeless Hotel / motel w/o emergency voucher Long-term care facility or nursing Home youth) Foster care or foster care group home Moved from one HOPWA funded project to HOPWA PH Permanent housing (there than RRH) for formerly homeless Place not meant for human habitation Moved from one HOPWA funded project to HOPWA TH persons Safe Haven Rental by client, with GPD TIP housing subsidy Psychiatric hospital or other psychiatric facility Rental, VASH subsidy Residential project or halfway house with no homeless criteria Substance abuse treatment facility or detox center Rental, (non-VASH) housing subsidy No Exit Interview completed Hospital (non-psychiatric) Owned, with subsidy Client doesn't know Jail, prison, or juvenile detention facility With family, permanent tenure Client refused Rental, no subsidy Other Owned, no subsidy If Other, please explain: ___________________________________________
DOH AIDS/HOPWA Individual Discharge Form Applicant (Head of Household) Information: First Name: ___________________________ Last Name: __________________________ Client ID#: ____________________ Project Exit Date: _____________________ Case Manager Assigned to Discharge: _____________________ Destination Type: Emergency shelter or hotel paid w/ voucher Transitional housing for homeless persons (including homeless youth) Permanent housing (there than RRH) for formerly homeless persons Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non-psychiatric) Jail, prison, or juvenile detention facility Rental, no subsidy Owned, no subsidy With family, temporary tenure With friends, temporary tenure Hotel / motel w/o emergency voucher Foster care or foster care group home Place not meant for human habitation Safe Haven Rental, VASH subsidy Rental, (non-VASH) housing subsidy Owned, with subsidy With family, permanent tenure With friends, permanent tenure Deceased Long-term care facility or nursing Home Moved from one HOPWA funded project to HOPWA PH Moved from one HOPWA funded project to HOPWA TH Rental by client, with GPD TIP housing subsidy Residential project or halfway house with no homeless criteria No Exit Interview completed Client doesn't know Client refused Other If Other, please explain: ___________________________________________
HMIS_AIDS_HOPWA_Individual_Discharge_Form.docx