Disability Assessment Does the client have a disabling condition expected to be of long duration and impedes ability to live independently? Yes No Client Client Refused     doesn’t know Will the If Yes, Expected to be of long-continued Condition be and indefinite duration and substantially Disability Type (If Yes) Start Date long term? Disability Determination impairs ability to live independently? Yes Yes Yes Know Know Doesn’t Doesn’t Alcohol Abuse _____/_____/_____ No No No Refused Refused Yes No Notes: Client doesn’t know Client Refused Alcohol and Yes Know Yes Yes Know Doesn’t Doesn’t _____/_____/_____ No Refused No Drug Abuse No Refused Yes No Notes: Client doesn’t know Client Refused Chronic Health Yes Know Yes Yes Know Doesn’t Doesn’t _____/_____/_____ No Refused No Condition No Refused Yes No Notes: Client doesn’t know Client Refused Developmental Yes Know Yes Yes Know Doesn’t Doesn’t Disability _____/_____/_____ No No Refused No Refused Yes No Notes: Client doesn’t know Client Refused Yes Know Yes Yes Know Doesn’t Doesn’t Drug Abuse _____/_____/_____ No No Refused No Refused Yes No Notes: Client doesn’t know Client Refused Yes Know Yes Yes Know Doesn’t Doesn’t HIV/AIDS _____/_____/_____ No No Refused No Refused Yes No Notes: Client doesn’t know Client Refused Mental Health Yes Yes Know Yes Know Doesn’t Doesn’t _____/_____/_____ No Refused No Problem No Refused Yes No Notes: Client doesn’t know Client Refused Physical Yes Know Yes Yes Doesn’t Know Doesn’t _____/_____/_____ No Refused No Disability No Refused Yes No Notes: Client doesn’t know Client Refused Continue to Chronic Homeless Assessment
Disability Assessment Does the client have a disabling condition expected to be of long duration and impedes ability to live independently?  Yes  No  Client doesn’t know  Client Refused Disability Type (If Yes) Start Date Will the Condition be long term? Disability Determination If Yes, Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? Alcohol Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Alcohol and Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Chronic Health Condition Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Developmental Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Drug Abuse Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: HIV/AIDS Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Mental Health Problem Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Physical Disability Yes No Client doesn’t know Client Refused _____/_____/_____ Yes No Yes No Doesn’t Know Refused Yes No Doesn’t Know Refused Notes: Continue to Chronic Homeless Assessment
SubCook_Initial_Intake_Assessment_20181001.docx