No Client doesn’t 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 ○ ○ Children’s Health Insurance (SCHIP) Private Pay Health Insurance ○ ○ Veteran’s Administration (VA) Medical Services State Health Insurance for Adults ○ ○ (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 Moved to Find Work ○ ○ Could Not Pay Utilities Problems with Public Benefits ○ ○ Discharge from Foster Care Reasons Related to My Sexual Orientation ○ ○ Discharged from Jail Relationship Problems or Family Break-up ○ ○ Discharged from Prison Unable to Pay Rent Mortgage ○ ○ Does Not Apply to Me Client doesn't know ○ ○ Family Member or Personal Illness Client refused ○ ○ Legal Problems Other ○ ○ Did you relocate to Colorado/Colorado Springs? No Client doesn’t know ○ ○ Client refused ○ Yes ○ Data not collected ○ If yes, why (select all that apply)? Care of sick relative Family Support ○ ○ Climate Medical Needs ○ ○ Colorado marijuana laws Natural Disaster ○ ○ Driver's Licenses/Identification Cards for Immigrants Needed services ○ ○ Employment Domestic Violence ○ ○ Signature of applicant stating all information is true and correct Date
○ No ○ Client doesn’t 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 ○ Children’s Health Insurance (SCHIP) ○ Private Pay Health Insurance ○ Veteran’s Administration (VA) Medical Services ○ State Health Insurance for Adults ○ (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 ○ Moved to Find Work ○ Could Not Pay Utilities ○ Problems with Public Benefits ○ Discharge from Foster Care ○ Reasons Related to My Sexual Orientation ○ Discharged from Jail ○ Relationship Problems or Family Break-up ○ Discharged from Prison ○ Unable to Pay Rent Mortgage ○ Does Not Apply to Me ○ Client doesn't know ○ Family Member or Personal Illness ○ Client refused ○ Legal Problems ○ Other Did you relocate to Colorado/Colorado Springs? ○ No ○ Client doesn’t know ○ Yes ○ Client refused ○ Data not collected If yes, why (select all that apply)? ○ Care of sick relative ○ Family Support ○ Climate ○ Medical Needs ○ Colorado marijuana laws ○ Natural Disaster ○ Driver's Licenses/Identification Cards for Immigrants ○ Needed services ○ Employment ○ Domestic Violence Signature of applicant stating all information is true and correct Date
COHMIS-Intake-form504.docx