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 Indian Health Services Program Yes No Other Specify: __________________________________________ Yes No – Do you have a disabling condition? Yes No Client Doesn’t 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 Doesn’t 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 Doesn’t Know Client Client Refused Refused Client Client Mental Health Problem Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Alcohol Abuse Yes   No Yes No Yes No Yes No Know Doesn’t Know Client Client Refused Refused Client Client Drug Abuse Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Both Alcohol and Drug Abuse Yes   No Yes No Yes No Yes No Doesn’t Know Doesn’t Know Client Client Refused Refused Client Client Has the client ever been a victim of domestic violence?      Yes No Client Doesn’t Know Client Refused Data Not Collected If yes, how long ago?  Within the past three months  More than a year ago  Three to six months ago  Client Doesn't know  From six to twelve months ago  Client Refused
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 Indian Health Services Program Yes No Other – Specify: __________________________________________ Do you have a disabling condition? Yes No Client Doesn’t 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 Doesn’t 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 Doesn’t 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 Doesn’t Know Client Refused  Yes No  Yes No Alcohol Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Both Alcohol and Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Has the client ever been a victim of domestic violence?  Yes  No  Client Doesn’t Know  Client Refused  Data Not Collected If yes, how long ago?  Within the past three months  More than a year ago  Three to six months ago  Client Doesn't know  From six to twelve months ago  Client Refused
coc-spc-entry-form-2016.docx