INTAKE / HMIS ENTRY FORM for the Unsheltered Provider HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix) DATE OF CONTACT COUNTY ARE THEY STAYING? (Describe in enough detail to find them again) SSN (HoH) DATE OF BIRTH TELEPHONE NUMBER EMAIL ADDRESS VETERAN STATUS (HoH) ETHNICITY (HoH) GENDER (HoH) Did Not Serve Active Non-Hispanic/Latino Male Transgender female to male     Duty in the US (Transgender man) Military Served Active Duty Hispanic / Latino Female Transgender male to female    in the US Military (Transgender woman) Does not identify as male, female, or  transgender PRIMARY RACE (HoH) Check All That Apply American Indian or Alaskan Black / African American Native / Hawaiian/Other Pacific Islander (NH)    Native (AI/AN) (B) Asian (A) White (W) Client refused Client doesn’t know     PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS: Relationship RACE(s) SOCIAL to HEAD OF DATE OF (choose VET NAME SECURITY GENDER HOUSEHOLD (Y/N) BIRTH from the (Y/N) NUMBER selection above) INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Over 3 Months and 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
INTAKE / HMIS ENTRY FORM for the Unsheltered Provider HEAD OF HOUSEHOLD NAME (HoH) (First, MI, Last, suffix) DATE OF CONTACT COUNTY ARE THEY STAYING? (Describe in enough detail to find them again) SSN (HoH) DATE OF BIRTH TELEPHONE NUMBER EMAIL ADDRESS 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)  Does not identify as male, female, or transgender PRIMARY RACE (HoH) Check All That Apply  American Indian or Alaskan Native (AI/AN)  Black / 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 DATE OF BIRTH Relationship to HEAD OF HOUSEHOLD RACE(s) (choose from the selection above) (Y/N) GENDER VET (Y/N) INFO NEEDED FOR HOUSEHOLD MEMBERS WITH DISABLING CONDITIONS NAME CONDITION Duration Over 3 Months and 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
2017-HMIS-Unsheltered-form.docx