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 doesn’t know ○ ○ Expected to substantially impair ability to live independently? Client refused ○ Yes ○ Data not collected ○ CHRONIC HEALTH CONDITION Clients] No Client doesn’t 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 doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ 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 ABUSE PROBLEM Clients] No Both alcohol and drug abuse ○ ○ Client doesn’t 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 ○ ○
○ 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected CHRONIC HEALTH CONDITION Clients] ○ No ○ Client doesn’t 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 doesn’t know ○ Yes ○ Client refused ○ Data not collected 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 ABUSE PROBLEM Clients] ○ No ○ Both alcohol and drug abuse ○ Alcohol abuse ○ Client doesn’t know ○ Client refused ○ Drug ○ Data not collected IF “ALCOHOL ABUSE” “DRUG ABUSE” OR “BOTH ALCOHOL AND DRUG ABUSE” – SPECIFY ○ No ○ Client doesn’t know
COHMIS-Intake-form504.docx