Data not collected ○ CHRONIC HEALTH CONDITION required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ HIV-AIDS required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO HIV-AIDS SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ MENTAL HEALTH PROBLEM required for SSVF] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO MENTAL HEALTH CONDITION SPECIFY “YES” – No Client know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ ○ substantially impairs ability to live independently? Yes Data not collected ○ SUBSTANCE ABUSE PROBLEM required for SSVF] No Both alcohol and drug abuse ○ ○ Client doesn’t know ○ Alcohol abuse ○ Client refused ○ Drug abuse Data not collected ○ ○ IF ABUSE” ABUSE” OR ALCOHOL AND DRUG ABUSE” SPECIFY “ALCOHOL “DRUG “BOTH – No Client know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ of Household and Adults, not DOMESTIC VIOLENCE VICTIM/SURVIVOR required for SSVF] No Client doesn’t know ○ ○
○ Data not collected CHRONIC HEALTH CONDITION required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HIV-AIDS – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected MENTAL HEALTH PROBLEM required for SSVF] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO MENTAL HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected SUBSTANCE ABUSE PROBLEM required for SSVF] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug abuse ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults, not required for SSVF] ○ No ○ Client doesn’t know
VA-combined-Project-Intake-HMIS-2017-rev07May2018.docx