Physical Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Developmental Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Chronic Health Condition Yes   No Yes No Yes No Yes No Know Doesn’t Know Client Client Refused Refused Client Client HIV/AIDS Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Mental Health Problem Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Alcohol Abuse Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Drug Abuse Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Both Alcohol and Drug Abuse Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Has the client ever been a victim of domestic violence? Yes No Client Client Data Doesn’t Know Refused Not Collected If yes, how long ago?  Within the past three months  More than a year ago  Three to six months ago  Client Doesn't know  From six to twelve months ago  Client Refused If yes, are you currently fleeing? Yes No  Client Doesn’t Know Client Refused Data Not Collected Employed?  Yes  No Client Doesn’t Know Client Refused Data Not Collected    If yes, Type of Employment:  Full-time  Part-time Seasonal/Sporadic Data Not Collected   If no, Why not Employed?  Looking for Work  Unable to Work Not Looking for Work Data Not Collected   General Health Status:  Excellent  Very Good  Good  Fair  Poor  Client Know  Client Refused  Data Not Collected Residential Move-In Date:
Physical Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Developmental Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Chronic Health Condition Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No HIV/AIDS Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Mental Health Problem Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Alcohol Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Both Alcohol and Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Has the client ever been a victim of domestic violence? Yes No Client Doesn’t Know Client Refused Data Not Collected If yes, how long ago?  Within the past three months  More than a year ago  Three to six months ago  Client Doesn't know  From six to twelve months ago  Client Refused If yes, are you currently fleeing? Yes No  Client Doesn’t Know Client Refused Data Not Collected Employed?  Yes  No  Client Doesn’t Know  Client Refused  Data Not Collected If yes, Type of Employment:  Full-time  Part-time  Seasonal/Sporadic  Data Not Collected If no, Why not Employed?  Looking for Work  Unable to Work  Not Looking for Work  Data Not Collected General Health Status:  Excellent  Very Good  Good  Fair  Poor  Client Know  Client Refused  Data Not Collected Residential Move-In Date:
vash-exit-2016-pending-approval.docx