Special Supplemental Nutrition Program for Women, Infants and Children (WIC) $ Yes No TANF Child Care services $ Yes No TANF transportation services $ Yes No Other TANF-funded services $ Yes No Section 8, public housing, or other ongoing rental assistance $ Yes No Temporary Rental Assistance $ Yes No Other Source Specify Source _____________________________________ $ Yes No – Is Client Covered by Health Insurance? Yes No Client Know Client Refused Data Not Collected Covered Health Insurance Type all that apply) MEDICAID Yes No MEDICARE Yes No State Children’s Health Insurance Program Yes No Veteran’s Administration (VA) Medical Services Yes No Employer-Provided Health Insurance Yes No Health Insurance obtained through COBRA Yes No State Health Insurance for Adults Yes No Private Pay Health Insurance Yes No Do you have a disability of long duration? Yes No Client Know Client Refused Data Not Collected Disability Type Expected to be of long-continued Documentation of Currently and indefinite duration and the disability and Receiving substantially impairs ability to live severity on file? Treatment or independently Services? 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 Know Client Client Refused Refused Client Client Chronic Health Condition Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client HIV/AIDS Yes   No Yes No Yes No Yes No Doesn’t Know Know Client Client Refused Refused Client Client Mental Health Problem Yes   No Yes No Yes No Yes No Know Doesn’t Know Client Client Refused Refused Client Client Disability information (cont.) Alcohol Abuse Yes   Yes No No Yes No Yes No Doesn’t Know Doesn’t Know Client Client
Yes No Special Supplemental Nutrition Program for Women, Infants and Children (WIC) $ Yes No TANF Child Care services $ Yes No TANF transportation services $ Yes No Other TANF-funded services $ Yes No Section 8, public housing, or other ongoing rental assistance $ Yes No Temporary Rental Assistance $ Yes No Other Source – Specify Source _____________________________________ $ Is Client Covered by Health Insurance? Yes No Client Know Client Refused Data Not Collected Covered Health Insurance Type all that apply) Yes No MEDICAID Yes No MEDICARE Yes No State Children’s Health Insurance Program Yes No Veteran’s Administration (VA) Medical Services Yes No Employer-Provided Health Insurance Yes No Health Insurance obtained through COBRA Yes No State Health Insurance for Adults Yes No Private Pay Health Insurance Do you have a disability of long duration? Yes No Client Know Client Refused Data Not Collected Disability Type Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently Documentation of the disability and severity on file? Currently Receiving Treatment or Services? 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 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 Doesn’t Know Client Refused  Yes No  Yes No HIV/AIDS Yes No Client 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 Know Client Refused  Yes No  Yes No Disability information (cont.) Alcohol Abuse Yes No Client Doesn’t Know Yes No Client Doesn’t Know  Yes No  Yes No
youth-outreach-intake-2015.docx