IF TO INCOME FROM ANY SOURCE INDICATE ALL SOURCES THAT “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 Families) Worker’s Compensation ○ ○ VA Service Connected Disability Compensation Other source ○ ○ VA Connected Disability Pension (specify): ○ Total monthly amount: RECEIVING BENEFITS​ of Household and Adults] 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 Women, Infants, ○ TANF Transportation Services ○ and Children (WIC) ○ Other (Specify): Other TANF-funded services ○ COVERED BY HEALTH INSURANCE Clients] No Client know ○ ○ Client refused ○ Yes ○ Data not collected ○ IF TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS “YES” MEDICAID Employer Provided Health Insurance ○ ○ MEDICARE Insurance Obtained through COBRA ○ ○ State Children’s Health Insurance (SCHIP) Private Pay Health Insurance ○ ○ Veteran’s Administration (VA) Medical Services State Health Insurance for Adults ○ ○ Other (specify) Indian Health Services Program ○ ○ Pikes Peak CoC Entry Questions Reasons or Contributing Factors to Homelessness Abuse or Violence in My Home Lost a Job Could Not Find Work ○ ○ Alcohol Substance Abuse Problems Medical Expenses ○ ○ Asked to Leave Mental Illness ○ ○ Bad Credit to Find Work ○ ○ Not Pay Utilities Problems with Public Benefits ○ ○ Reasons Related to My Sexual ○ ○ Discharge from Foster Care Orientation Relationship Problems or Family ○ ○ Discharged from Jail
IF “YES” TO INCOME FROM ANY SOURCE – INDICATE ALL SOURCES THAT 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 Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension (specify): 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 Women, Infants, and Children (WIC) ○ TANF Transportation Services ○ Other (Specify): ○ Other TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client know ○ Yes ○ Client refused ○ Data not collected IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health Insurance ○ MEDICARE ○ Insurance Obtained through COBRA ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ Other (specify) ○ Indian Health Services Program Pikes Peak CoC Entry Questions Reasons or Contributing Factors to Homelessness ○ Abuse or Violence in My Home ○ Lost a Job Could Not Find Work ○ Alcohol Substance Abuse Problems ○ Medical Expenses ○ Asked to Leave ○ Mental Illness ○ Bad Credit ○ to Find Work ○ Not Pay Utilities ○ Problems with Public Benefits ○ Discharge from Foster Care ○ Reasons Related to My Sexual Orientation ○ Discharged from Jail ○ Relationship Problems or Family
COHMIS-Exit-form504.docx