INTAKE ASSESSMENT/ NETMIS Interface Residential Program CDS CONFIDENTIAL HMIS # _________________ Assessment HUD-40118 Home Zip Code: _______________ How long at that Where did you stay last night? __ Don’t know __ 1 week or less __ Emergency Shelter __ More than 3 __ Foster Care/Group Home months __ Hospital __ More than 1 __ Hotel/Motel without Emergency INTAKE ASSESSMENT/ NETMIS - page 2 week Shelter __ 1 Year or longer __ Jail/ Prison/ Juvenile Facility __ 1 to 3 Months __ Living with Family __ Living with Friends Homeless? __ __ Own house apartment __ Yes __ No __ Place not meant for habitation __ Psychiatric Hospital or Facility __ Refused Domestic Violence __ Rental House Apartment Victim? __ Substance Abuse treatment center __ Yes __ No __ Transitional Housing for homeless
INTAKE ASSESSMENT/ NETMIS Interface Residential Program CDS CONFIDENTIAL HMIS # _________________ Assessment HUD-40118 Home Zip Code: _______________ Where did you stay last night? __ Don’t know __ Emergency Shelter __ Foster Care/Group Home __ Hospital __ Hotel/Motel without Emergency Shelter __ Jail/ Prison/ Juvenile Facility __ Living with Family __ Living with Friends __ __ Own house apartment __ Place not meant for habitation __ Psychiatric Hospital or Facility __ Refused __ Rental House Apartment __ Substance Abuse treatment center __ Transitional Housing for homeless How long at that __ 1 week or less __ More than 3 months __ More than 1 week __ 1 Year or longer __ 1 to 3 Months Homeless? __ Yes __ No Domestic Violence Victim? __ Yes __ No INTAKE ASSESSMENT/ NETMIS - page 2
intake_assessment_netmis_res.docx