Previous Benefit ESG ESG assistance IDHS HP assistance in last in last 36 months assistance in 36 months previous 2 years Initial Intake Assessment HH Member Supplemental Head of Household Name: HMIS ID# Fill-in after ServicePoint Entry Entry Date (Project Start) Month / Day / Year Client does not Client Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) 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 Child Other Relation HoH’s HoH’s NA NA (to HoH) Spouse/Partner Other: Non-Relation HoH’s 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 Other American Indian or Black/African American Native Hawaiian or Other Secondary Alaskan Native Pacific Islander Race (Leave NA Blank if None) Asian White Other Primary English Spanish Other, Language   Yes No
Previous Benefit ESG assistance in last 36 months ESG assistance in last 36 months IDHS HP assistance in previous 2 years Head of Household Name: Initial Intake Assessment HH Member Supplemental HMIS ID# Fill-in after ServicePoint Entry Entry Date (Project Start) Month / Day / Year Name of Head of Household (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not 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) HoH’s Child HoH’s Spouse/Partner HoH’s Other Relation Other: Non-Relation NA NA 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 Other   Secondary Race (Leave Blank if None) American Indian or Alaskan Native Asian Black/African American White Native Hawaiian or Other Pacific Islander Other NA Primary Language English Spanish Other, Yes No  
SubCook_Initial_Intake_Assessment.docx