Housing Assessment at Exit: Able to maintain the housing they had at project entry Moved to a transitional or temporary housing facility or Client doesn’t know Moved to new housing unit program Client refused Moved in with family/friends on a temporary basis Client became homeless – moving to a shelter or other place Client died Moved in with family/friends on a permanent basis unfit for human habitation Data not collected Client went to jail/prison Non-Cash Benefit from any source? No Yes Client doesn’t know Client refused Data Not Collected Non-cash benefits received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. Non- Cash Benefits List YES / NO (SNAP) Food Stamps Special Supplemental Nutrition Program for WIC TANF Child Care Services TANF Transportation Other TANF Funded Services Client Doesn't know Client Refused Other (Please Specify): Covered by Health Insurance: No Yes Client doesn’t know Client refused Data Not Collected
Housing Assessment at Exit: Able to maintain the housing they had at project entry Moved to new housing unit Moved in with family/friends on a temporary basis Moved in with family/friends on a permanent basis Moved to a transitional or temporary housing facility or program Client became homeless – moving to a shelter or other place unfit for human habitation Client went to jail/prison Client doesn’t know Client refused Client died Data not collected Non-Cash Benefit from any source? No Yes Client doesn’t know Client refused Data Not Collected Non-cash benefits received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household. Non- Cash Benefits List YES / NO (SNAP) Food Stamps Special Supplemental Nutrition Program for WIC TANF Child Care Services TANF Transportation Other TANF Funded Services Client Doesn't know Client Refused Other (Please Specify): Covered by Health Insurance: No Yes Client doesn’t know Client refused Data Not Collected
HMIS_AIDS_HOPWA_Individual_Discharge_Form.docx