Housing Move-In Date: ____/____/__________ LIVING SITUATION TYPE OF RESIDENCE [Head of Household and Adults ] Emergency shelter, including hotel/motel paid Rental by client, no ongoing housing ○ ○ for w/ voucher subsidy Foster care home or foster care group home Rental by client, with GPD TIP ○ ○ Hospital or residential medical Rental by client, with VASH subsidy ○ ○ facility Hotel or motel paid for without emergency shelter Rental by client, with other ongoing ○ ○ voucher housing subsidy Residential project or halfway house Interim Housing ○ ○ with no homeless criteria Jail, prison or juvenile detention facility Safe ○ ○ Staying or living in a family member’s Long-term care facility or nursing home ○ ○ room, apartment or house Staying or living in a friend’s room, Owned by client, no housing subsidy ○ ○ apartment or Substance abuse treatment facility Owned by client, with ongoing housing subsidy ○ ○ detox center Permanent housing (other than RRH) for formerly Transitional housing for homeless ○ ○ homeless persons persons (including homeless Client doesn’t know ○ Place not meant for habitation ○ Client refused ○ Psychiatric hospital or other psychiatric facility Data not collected ○ ○ LENGTH OF STAY IN PRIOR LIVING SITUATION One month or more, but One night or less Client doesn’t know ○ ○ ○ less than 90 days 90 days or more, but Two to six nights Client refused ○ ○ ○ less than one year One week or more, but less than One year or longer Data not collected ○ ○ ○ one month LENGTH OF STAY LESS THAN 7 NIGHTS [TH, PH] No Yes ○ ○ LENGTH OF STAY LESS THAN 90 DAYS [If type of stay is Interim Housing- Facility /Institution etc] No Yes ○ ○ ON THE NIGHT BEFORE - DID YOU STAY - STREETS, IN EMERGENCY SHELTER, SAFE HAVEN [Head of Household and Adults] Yes No ○ ○ Approximate Date Homelessness Started ____/____/__________
Housing Move-In Date: ____/____/__________ LIVING SITUATION TYPE OF RESIDENCE [Head of Household and Adults ] ○ Emergency shelter, including hotel/motel paid for w/ voucher ○ Rental by client, no ongoing housing subsidy ○ Foster care home or foster care group home ○ Rental by client, with GPD TIP ○ Hospital or residential medical facility ○ Rental by client, with VASH subsidy ○ Hotel or motel paid for without emergency shelter voucher ○ Rental by client, with other ongoing housing subsidy ○ Interim Housing ○ Residential project or halfway house with no homeless criteria ○ Jail, prison or juvenile detention facility ○ Safe ○ Long-term care facility or nursing home ○ Staying or living in a family member’s room, apartment or house ○ Owned by client, no housing subsidy ○ Staying or living in a friend’s room, apartment or ○ Owned by client, with ongoing housing subsidy ○ Substance abuse treatment facility detox center ○ Permanent housing (other than RRH) for formerly homeless persons ○ Transitional housing for homeless persons (including homeless ○ Place not meant for habitation ○ Client doesn’t know ○ Client refused ○ Psychiatric hospital or other psychiatric facility ○ Data not collected LENGTH OF STAY IN PRIOR LIVING SITUATION ○ One night or less ○ One month or more, but less than 90 days ○ Client doesn’t know ○ Two to six nights ○ 90 days or more, but less than one year ○ Client refused ○ One week or more, but less than one month ○ One year or longer ○ Data not collected LENGTH OF STAY LESS THAN 7 NIGHTS [TH, PH] ○ No ○ Yes LENGTH OF STAY LESS THAN 90 DAYS [If type of stay is Interim Housing- Facility /Institution etc] ○ No ○ Yes ON THE NIGHT BEFORE - DID YOU STAY - STREETS, IN EMERGENCY SHELTER, SAFE HAVEN [Head of Household and Adults] ○ Yes ○ No Approximate Date Homelessness Started ____/____/__________
CoC-Project-Intake-HMIS-2017-rev14Sept17.docx