Exit Date ServicePoint (HoH) ID: Project Name Head of Household Name SSN Last four digits first middle last suffix If Partial Household Exit (if the household is existing, skip to Destination) Name of Client(s) Exiting Client ID Reason for Leaving Criminal Disagreement with Left for housing opp. Completed Program Completed Step activity/violence rules/persons Before completing program Needs could not be Non-compliance with Non-payment of rent Reached maximum met program time allowed Unknown/Disappeared Destination (Where will you stay tonight?) Place not meant for Emergency Shelter Transitional Housing habitation (e.g. vehicle, Hotel or motel paid for Deceased (including or motel for homeless persons abandoned building, without emergency paid for with an (including homeless bus/train/subway shelter voucher emergency shelter youth) station/airport or voucher) outside) Rental by client, no Rental by client, with Rental by client, with Rental by client, Residential project or ongoing housing VASH subsidy GPD TIP With other ongoing halfway house with no subsidy (Veterans Affairs) subsidy subsidy homeless criteria Hospital or other Staying or living with Staying or living with Staying or living with residential Psychiatric hospital or family, permanent family, temporary friends, permanent psychiatric medical other facility tenure tenure tenure facility Staying or living with Jail, prison or juvenile Substance abuse Moved from on from one HOPWA friends, temporary detention facility treatment facility or HOPWA funded funded project to tenure detox center project to HOPWA PH HOPWA TH Owned by client, no Owned by client, with Permanent housing ongoing housing ongoing housing (other than RRH) for Long-term care facility Safe Haven (non in subsidy subsidy formerly homeless or nursing home Alameda Co.) person Foster care home or Rental by client, with foster care group home Client doesn’t know Client refused Other RRH or equivalent subsidy Any Adult in the Household currently receiving income? Yes No (identify below)
Exit Date ServicePoint (HoH) ID: Project Name Head of Household Name first middle last suffix SSN Last four digits If Partial Household Exit (if the household is existing, skip to Destination) Name of Client(s) Exiting Client ID Reason for Leaving Completed Program Completed Step Criminal activity/violence Disagreement with rules/persons Left for housing opp. Before completing program Needs could not be met Non-compliance with program Non-payment of rent Reached maximum time allowed Unknown/Disappeared Destination (Where will you stay tonight?) Deceased Emergency Shelter (including or motel paid for with an emergency shelter voucher) Transitional Housing for homeless persons (including homeless youth) Place not meant for habitation (e.g. vehicle, abandoned building, bus/train/subway station/airport or outside) Hotel or motel paid for without emergency shelter voucher Rental by client, no ongoing housing subsidy Rental by client, with VASH subsidy (Veterans Affairs) Rental by client, with GPD TIP subsidy Rental by client, With other ongoing subsidy Residential project or halfway house with no homeless criteria Hospital or other residential medical facility Psychiatric hospital or other psychiatric facility Staying or living with family, permanent tenure Staying or living with family, temporary tenure Staying or living with friends, permanent tenure Staying or living with friends, temporary tenure Jail, prison or juvenile detention facility Substance abuse treatment facility or detox center Moved from on HOPWA funded project to HOPWA PH from one HOPWA funded project to HOPWA TH Owned by client, no ongoing housing subsidy Owned by client, with ongoing housing subsidy Permanent housing (other than RRH) for formerly homeless person Long-term care facility or nursing home Safe Haven (non in Alameda Co.) Foster care home or foster care group home Client doesn’t know Client refused Other Rental by client, with RRH or equivalent subsidy Any Adult in the Household currently receiving income? Yes (identify below) No
2017_Standard_Exit_Form_CoC_ESG_VA_OTH.docx