SubCook Initial Intake Assessment Head of Household HMIS ID# Fill-in after ServicePoint Entry Entry Date Date of Engagement Housing Move-in Date (Project Start) (ES/SO) (PH, PSH, RRH) Month / Day / Year Month / Day / Year Month / Day / Year Client Client Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) doesn’t know refused First Name Middle Name   Last Name Alias/Suffix   Approx. or Partial SSN    SSN Reported Veteran Status is on the Client Profile Tab and may need to be updated Yes No   Veteran Status if the client is already in ServicePoint. Relationship Use a separate HH Member Supplemental page SELF Number in Household: (to HoH) for each additional HH member Approx. or Partial Date of Birth    DOB Reported Male Trans Female: M to F Gender Non-Confirming Gender   Trans Male: F to M Female (i.e. not exclusively M or F) Ethnicity   Non-Hispanic/Latino Hispanic/Latino American Indian or Native Hawaiian or Other Black/African American Alaskan Native Pacific Islander Primary Race   White Asian American Indian or Native Hawaiian or Other Black/African American Secondary Alaskan Native Pacific Islander Race (Leave NA Blank if None) Asian White Primary English Spanish Other, Language   Yes No (If Yes) how long ago was the last incident? Domestic Within the past 3 months 3-6 months ago 6-12 months ago    Violence More than a year Client Client Refused Doesn’t Know  Victim/Survivor (If Yes) are you currently fleeing? Yes No Client Does Not Know Client     Continue to Disability Assessment Client Name:
SubCook Initial Intake Assessment Head of Household HMIS ID# Fill-in after ServicePoint Entry Entry Date (Project Start) Date of Engagement (ES/SO) Housing Move-in Date (PH, PSH, RRH) Month / Day / Year Month / Day / Year Month / Day / Year Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client doesn’t know Client refused First Name Middle Name   Last Name Alias/Suffix   SSN Approx. or Partial SSN Reported    Veteran Status Yes No Veteran Status is on the Client Profile Tab and may need to be updated if the client is already in ServicePoint.   Relationship (to HoH) SELF Number in Household: Use a separate HH Member Supplemental page for each additional HH member Date of Birth Approx. or Partial DOB Reported    Gender Male Female Trans Female: M to F Trans Male: F to M Gender Non-Confirming (i.e. not exclusively M or F)   Ethnicity Non-Hispanic/Latino Hispanic/Latino   Primary Race American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander NA Primary Language English Spanish Other, Domestic Violence Victim/Survivor Yes No   (If Yes) how long ago was the last incident?  Within the past 3 months  3-6 months ago  6-12 months ago More than a year Client Doesn’t Know  Client Refused (If Yes) are you currently fleeing?  Yes  No  Client Does Not Know  Client Continue to Disability Assessment Client Name:
SubCook_Initial_Intake_Assessment_20181001.docx