IF TO HIV-AIDS SPECIFY “YES” – No Client doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ MENTAL HEALTH PROBLEM Clients] No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO MENTAL 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 ○ SUBSTANCE PROBLEM Clients] No Both alcohol and drug abuse ○ ○ Client know ○ Alcohol abuse ○ Client refused ○ Drug Data not collected ○ ○ IF ABUSE” ABUSE” OR ALCOHOL AND DRUG ABUSE” SPECIFY “ALCOHOL “DRUG “BOTH – 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 ○ DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] No Client doesn’t ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO DOMESTIC VIOLENCE “YES” WHEN EXPERIENCE OCCURRED Within the past 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 ○ ○ Are you currently fleeing? Client refused ○ Yes ○ Data not collected ○ INCOME FROM ANY SOURCE of Household and Adults] No Client doesn’t ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT APPLY “YES” – Income Source Amount Income Source
IF “YES” TO HIV-AIDS – SPECIFY Expected to substantially impair ability to live independently? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected MENTAL HEALTH PROBLEM Clients] ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO MENTAL 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 SUBSTANCE PROBLEM Clients] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client know ○ Client refused ○ Drug ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – 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 DOMESTIC VIOLENCE VICTIM/SURVIVOR of Household and Adults] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not collected IF “YES” TO DOMESTIC VIOLENCE WHEN EXPERIENCE OCCURRED ○ Within the past 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 ○ Yes ○ Client refused ○ Data not collected INCOME FROM ANY SOURCE of Household and Adults] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not collected IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT APPLY Income Source Amount Income Source
CoC-Project-Intake-HMIS-2017-rev14Sept17.docx