Region 16 Homeless Intake Date: _____/_____/_______ Name: _____________________________________________________ Emergency Contact Information: Name Phone # Address Relationship HUD 40118 ASSESSMENT Are you homeless? YES NO What was the approximate date that your homelessness started? __________________________ How many times have you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ What is the total number of months you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ Is there a disability of a long duration for any family member? YES NO INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Impairs Ability to Documentation of Receiving Treatment Than 3 Months Live Independently Disability & Severity for this disability? on File? Physical Developmental Yes No Yes No Yes No Yes No Mental HIV/AIDS Health Alcohol Drug & Drug Abuse Abuse Physical Developmental Yes No Yes No Yes No Yes No Mental HIV/AIDS Health Alcohol Drug & Drug Abuse Abuse Physical Developmental Yes No Yes No Yes No Yes No Mental HIV/AIDS Health Alcohol Drug & Drug Abuse Abuse Physical Developmental Yes No Yes No Yes No Yes No Mental HIV/AIDS Health Alcohol Drug & Drug Abuse Abuse What is your current/prior residence? _______________________________________________ How long did you live at the prior/current living situation? _______________________________
Region 16 Homeless Intake Date: _____/_____/_______ Name: _____________________________________________________ Emergency Contact Information: Name Phone # Address Relationship HUD 40118 ASSESSMENT Are you homeless? YES NO What was the approximate date that your homelessness started? __________________________ How many times have you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ What is the total number of months you been on the street, place not meant for human habitation, emergency shelter, or hotel/motel paid for by a government or community organization in the past 3 years, including today? ______ Is there a disability of a long duration for any family member? YES NO INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Than 3 Months Impairs Ability to Live Independently Documentation of Disability & Severity on File? Receiving Treatment for this disability? Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No Physical Developmental Mental Health HIV/AIDS Alcohol & Drug Abuse Drug Abuse Yes No Yes No Yes No Yes No What is your current/prior residence? _______________________________________________ How long did you live at the prior/current living situation? _______________________________
TAB-1-ASSESSMENT-Revised-March-2017.docx