INTAKE / HMIS ENTRY FORM for homeless projects CONDITION 1 MET CONDITION 2 MET CONDITION 3 MET PROJECT START DATE Information provided by the client or from Client as indicated they want Client is approved to access / /    the referral indicates they are eligible to be housed in the project services/housing through the project HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix) EXISTING HOUSEHOLD INFO This form is adding client(s) to an existing household Yes No If yes, HMIS Client ID (HoH) ____________ SSN (HoH) DATE OF BIRTH COC LOCATION CODE COUNTY WHERE SERVED BOS OH-507 ____________  Other VETERAN STATUS (HoH) ETHNICITY (HoH) GENDER (HoH) Did Not Serve Active Duty in Non-Hispanic/Latino Male Transgender female to male     the US Military (Transgender man) Served Active Duty in the Hispanic / Latino Female Transgender male to female    US Military (Transgender woman) Gender Non-Conforming  PRIMARY RACE (HoH) All That Apply American Indian or Alaskan / African American (B) Native / Hawaiian/Other Pacific Islander (NH)    Native (AI/AN) Asian (A) White (W) Client refused Client doesn’t know     PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS: Relationship RACE(s) SOCIAL SECURITY to HEAD OF (choose Veteran NAME DOB Gender NUMBER HOUSEHOLD from the (Y/N) (Y/N) selection above) INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Than 3 Months & Impairs Ability to Live Independently Health Condition Health Yes No Physical Developmental Chronic Mental Abuse Abuse & Drug Abuse HIV/AIDS Drug Alcohol Alcohol Health Condition Health Yes No Physical Developmental Chronic Mental Abuse Abuse & Drug Abuse HIV/AIDS Drug Alcohol Alcohol Health Condition Health Yes No Physical Developmental Chronic Mental Abuse Abuse & Drug Abuse HIV/AIDS Drug Alcohol Alcohol Health Condition Health Yes No Physical Developmental Chronic Mental Abuse Abuse & Drug Abuse HIV/AIDS Drug Alcohol Alcohol
INTAKE / HMIS ENTRY FORM for homeless projects CONDITION 1 MET CONDITION 2 MET CONDITION 3 MET PROJECT START DATE  Information provided by the client or from the referral indicates they are eligible  Client as indicated they want to be housed in the project  Client is approved to access services/housing through the project / / HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix) EXISTING HOUSEHOLD INFO This form is adding client(s) to an existing household Yes No If yes, HMIS Client ID (HoH) ____________ SSN (HoH) DATE OF BIRTH COC LOCATION CODE COUNTY WHERE SERVED  BOS OH-507 Other ____________ VETERAN STATUS (HoH) ETHNICITY (HoH) GENDER (HoH)  Did Not Serve Active Duty in the US Military  Non-Hispanic/Latino  Male  Transgender female to male (Transgender man) Served Active Duty in the US Military  Hispanic / Latino  Female  Transgender male to female (Transgender woman)  Gender Non-Conforming PRIMARY RACE (HoH) All That Apply  American Indian or Alaskan Native (AI/AN)  / African American (B)  Native / Hawaiian/Other Pacific Islander (NH)  Asian (A)  White (W)  Client refused  Client doesn’t know PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS: NAME SOCIAL SECURITY NUMBER DOB Relationship to HEAD OF HOUSEHOLD RACE(s) (choose from the selection above) (Y/N) Gender Veteran (Y/N) INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Longer Than 3 Months & Impairs Ability to Live Independently Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No Physical Developmental Chronic Health Condition Mental Health HIV/AIDS Drug Abuse Alcohol Abuse Alcohol & Drug Abuse Yes No
2017-HMIS-Intake-Form-All-Programs.docx