Alimony and 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 Needy Families) Worker’s Compensation ○ ○ VA Service Connected Disability Other source ○ ○ Compensation Specify Other” VA Connected Disability Pension ○ 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, ○ TANF Transportation Services ○ Infants, and Children (WIC) ○ (Specify): TANF-funded services ○ COVERED BY HEALTH INSURANCE Clients] No Client doesn’t ○ ○ Client refused ○ Yes ○ Data not ○ IF TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS “YES” MEDICAID Employer Provided Health ○ ○ MEDICARE Insurance Obtained through ○ ○ State Children’s Health Insurance (SCHIP) Private Pay Health Insurance ○ ○ Veteran’s Administration (VA) Medical Services Health Insurance for Adults ○ ○ Other (specify): Indian Health Services Program ○ ○ PRIMARY LANGUAGE Clients, optional] English Mandarin ○ ○ Spanish Tagalog ○ ○ Other ○ Vietnamese ○ Unknown ○ Signature of applicant stating all information is true and correct Date
○ Alimony and 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 Needy Families) ○ Worker’s Compensation ○ VA Service Connected Disability Compensation ○ Other source ○ VA Connected Disability Pension Specify Other” 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 ○ (Specify): ○ TANF-funded services COVERED BY HEALTH INSURANCE Clients] ○ No ○ Client doesn’t ○ Yes ○ Client refused ○ Data not IF “YES” TO HEALTH INSURANCE HEALTH INSURANCE COVERAGE DETAILS ○ MEDICAID ○ Employer Provided Health ○ MEDICARE ○ Insurance Obtained through ○ State Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ Health Insurance for Adults ○ Other (specify): ○ Indian Health Services Program PRIMARY LANGUAGE Clients, optional] ○ English ○ Mandarin ○ Spanish ○ Tagalog ○ Vietnamese ○ Other ○ Unknown Signature of applicant stating all information is true and correct Date
CoC-Project-Intake-HMIS-2017-rev14Sept17.docx