Expected to be of long-continued and indefinite duration and Client refused ○ substantially impairs ability to live independently? Yes ○ ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DOMESTIC VIOLENCE “YES” WHEN EXPERIENCE OCCURRED Within the past three months One year ago or more ○ ○ Client doesn’t know ○ Three to six months ago (excluding six months exactly) ○ Client refused ○ Six months to one year ago (excluding one year exactly) Data not collected ○ ○ No Client doesn’t know ○ ○ Are you currently fleeing? Client refused ○ Yes ○ Data not collected ○ INCOME FROM ANY SOURCE of Household and Adults] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY “YES” – Income Source Amount Income Source Amount Alimony and Other Spousal Support Child support ○ ○ Pension or Retirement income from former job Earned Income ○ ○ Retirement Income from Social Security General Assistance (GA) ○ ○ Social Security Disability Insurance (SSDI) Private Disability Insurance ○ ○ Supplemental Security Income (SSI) Unemployment Insurance ○ ○ TANF (Temporary Assist for Needy Families) Worker’s Compensation ○ ○ VA Service Connected Disability Compensation Other source ○ ○ Specify Other” VA Connected Disability Pension ○ Total monthly amount: of Household and Adults] RECEIVING BENEFITS​ Client doesn’t know No ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO BENEFITS INDICATE ALL SOURCES THAT APPLY “YES” – ○ Supplemental Nutrition Assistance Program (SNAP) TANF Childcare Services ○ Special Supplemental Nutrition Program for Infants, and ○ TANF Transportation Services ○ Children (WIC) ○ Other (Specify): Other TANF-funded services ○ COVERED BY HEALTH INSURANCE Clients]
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? ○ Yes ○ Client refused ○ Data not collected DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED ○ Within the past three months ○ One year ago or more ○ Three to six months ago (excluding six months exactly) ○ Client doesn’t know ○ Client refused ○ Six months to one year ago (excluding one year exactly) ○ Data not collected Are you currently fleeing? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source Amount ○ Alimony and Other Spousal Support ○ Child support ○ Pension or Retirement income from former job ○ Earned Income ○ Retirement Income from Social Security ○ General Assistance (GA) ○ Social Security Disability Insurance (SSDI) ○ Private Disability Insurance ○ Supplemental Security Income (SSI) ○ Unemployment Insurance ○ TANF (Temporary Assist for Needy Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Specify Other” Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO BENEFITS – INDICATE ALL SOURCES THAT APPLY ○ Supplemental Nutrition Assistance Program (SNAP) ○ TANF Childcare Services ○ Special Supplemental Nutrition Program for Infants, and Children (WIC) ○ TANF Transportation Services ○ Other (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients]
COHMIS-Intake-form504.docx