Number of times the client has been on the streets, ES, or Safe Haven in the last 3 years One Time Client doesn’t know ○ ○ Two Times Client refused ○ ○ Three Times Data not collected ○ ○ Four or More Times ○ Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years One month (this time is the first month) Client doesn’t know ○ ○ months (specify number of months): ________ Client refused ○ ○ More than 12 months Data not collected ○ ○ DISABLING CONDITION Clients] Client know No ○ ○ Client refused ○ Yes ○ Data not collected ○ PHYSICAL DISABILITY Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO PHYSICAL DISABILITY SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ DEVELOPMENTAL DISABILITY Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DEVELOPMENTAL DISABILITY SPECIFY “YES” – No Client know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ CHRONIC HEALTH CONDITION Clients] No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO CHRONIC HEALTH CONDITION SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ Data not collected ○ HIV-AIDS Clients] No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○
Number of times the client has been on the streets, ES, or Safe Haven in the last 3 years ○ One Time ○ Client doesn’t know ○ Two Times ○ Client refused ○ Three Times ○ Data not collected ○ Four or More Times Number of Months homeless on the streets, ES, or Safe Haven in the last 3 years ○ One month (this time is the first month) ○ Client doesn’t know ○ months (specify number of months): ________ ○ Client refused ○ More than 12 months ○ Data not collected DISABLING CONDITION Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected PHYSICAL DISABILITY Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO PHYSICAL DISABILITY – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected DEVELOPMENTAL DISABILITY Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DEVELOPMENTAL DISABILITY – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO CHRONIC HEALTH CONDITION – SPECIFY Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected HIV-AIDS Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected
CoC-Project-Intake-HMIS-2017-rev14Sept17.docx