or more or more 1 2 3 4 1 2 3 4 5 6 7 8 9 10 11 12 ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING CASH INCOME FROM AND SOURCE? YES NO   Amount Recipient(s) Source Source Amount Recipient(s) Alimony or spousal Security Income $  Social $ support (SSI) Sec Disability Income $ Social $ assistance/TANF Cash (SSDI) $ $ support Child Unemployment Service Connected $ VA $ Income Earned Disability $ $ from a former job Pension Pension Veteran's from Social $ Retirement $ Compensation Worker’s Security $ Disability Insurance Assistance $ Private General Sources? Sources? Other $ $ Source___________________ Source_________________ TOTAL MONTHLY INCOME TOTAL MONTHLY INCOME $ $ (record separately for each adult) (record separately for each adult) * income for a goes under the adult receiving it* ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING NON CASH INCOME? YES NO   Recipient(s) Source Recipient(s) Source Food Stamps - Amount $ TANF care services   WIC TANF transportation services   Other: _____________________ Other TANF-funded services   ANYONE IN THE HOUSEHOLD RECEIVING HEALTH INSURANCE? YES NO   Recipient(s) Recipient(s) Source Source Health Employer-provided Medicaid  Insurance insurance obtained Health Medicare through COBRA Children’s Health State Pay Health Insurance Private Insurance Program (SCHIP) Administration (VA) Veteran’s Health Insurance for Adults Medical Services Health Services Program Indian RRH & PSH ONLY - HOUSING MOVE-IN DATE (Normally not known at Entry): Move-In Date (Month/Day/Year) : / / ADULTS AFFECTED BY DOMESTIC VIOLENCE YES NO   NAME EXTENT OF DOMESTIC VIOLENCE Within past 3 months the past 6-12 months  Within Within the past 3-6 months than 1 year ago  More Currently Fleeing? YesNo NAME EXTENT OF DOMESTIC VIOLENCE Within past 3 months the past 6-12 months  Within Within the past 3-6 months More than 1 year ago   Currently Fleeing? YesNo
1 2 3 4 or more 1 2 3 4 5 6 7 8 9 10 11 12 or more ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING CASH INCOME FROM AND SOURCE?  YES  NO Source Amount Recipient(s) Source Amount Recipient(s)  Alimony or spousal support $ Social Security Income (SSI) $ Cash assistance/TANF $ Social Sec Disability Income (SSDI) $ Child support $ Unemployment $ Earned Income $ VA Service Connected Disability $ Pension from a former job $ Veteran's Pension $ Retirement from Social Security $ Worker’s Compensation $ Private Disability Insurance $ General Assistance $ Sources? Source___________________ $ Other Sources? Source_________________ $ TOTAL MONTHLY INCOME (record separately for each adult) $ TOTAL MONTHLY INCOME (record separately for each adult) $ * income for a goes under the adult receiving it* ADULTS IN THE HOUSEHOLD CURRENTLY RECEIVING NON CASH INCOME?  YES  NO Source Recipient(s) Source Recipient(s)  Food Stamps - Amount $  TANF care services  WIC  TANF transportation services  Other: _____________________  Other TANF-funded services ANYONE IN THE HOUSEHOLD RECEIVING HEALTH INSURANCE?  YES  NO Source Recipient(s) Source Recipient(s)  Medicaid Employer-provided Health Insurance Medicare Health insurance obtained through COBRA State Children’s Health Insurance Program (SCHIP) Private Pay Health Insurance Veteran’s Administration (VA) Medical Services Health Insurance for Adults Indian Health Services Program RRH & PSH ONLY - HOUSING MOVE-IN DATE (Normally not known at Entry): Move-In Date (Month/Day/Year) : / / ADULTS AFFECTED BY DOMESTIC VIOLENCE  YES  NO NAME EXTENT OF DOMESTIC VIOLENCE  Within past 3 months Within the past 6-12 months  Within the past 3-6 months More than 1 year ago Currently Fleeing? YesNo NAME EXTENT OF DOMESTIC VIOLENCE  Within past 3 months Within the past 6-12 months  Within the past 3-6 months  More than 1 year ago Currently Fleeing? YesNo
2017-HMIS-Intake-Form-All-Programs.docx