CT HMIS PATH (Outreach) Exit Revised 5/24/2018 Project End Date: Case Manager Assigned to Discharge: _____________________ _____________________ Discharge Address: __________________________________________________________________________________________________________ Relationship to Head of Household Member Name HMIS ID# Date of Birth Gender Household Self Destination Type: Emergency shelter or hotel paid w/ voucher With family, temporary tenure Deceased Transitional housing for homeless persons (including homeless With friends, temporary tenure Long-term care facility or nursing Home youth) Hotel / motel w/o emergency voucher Moved from one HOPWA funded project to HOPWA PH Permanent housing (other than RRH) for homeless Foster care or foster care group home Moved from one HOPWA funded project to HOPWA TH persons Place not meant for human habitation Rental by client, with GPD TIP housing subsidy Psychiatric hospital or other psychiatric facility Safe Haven Residential project or halfway house with no homeless criteria Substance abuse treatment facility or detox center Rental, VASH subsidy No Exit Interview completed Hospital (non-psychiatric) Rental, (non-VASH) housing subsidy Client doesn't know Jail, prison, or juvenile detention facility Owned, with subsidy Client refused Rental, no subsidy With family, permanent tenure Other Owned, no subsidy With friends, permanent tenure If Other, please explain: ___________________________________________
CT HMIS PATH (Outreach) Exit Revised 5/24/2018 Project End Date: _____________________ Case Manager Assigned to Discharge: _____________________ Discharge Address: __________________________________________________________________________________________________________ Household Member Name Date of Birth Gender Relationship to Head of Household HMIS ID# Self Destination Type: Emergency shelter or hotel paid w/ voucher Transitional housing for homeless persons (including homeless youth) Permanent housing (other than RRH) for 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%2BPATH%2BFamily%2BDischarge%2BForm%2B-%2B7.2.docx