HH HH HH HH Head of Member Member Member Member Household 1 2 3 4 Physical Disability: Yes, No, Client Know, Client Refused If yes, Expected to be of and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused Developmental Disability: Yes, No, Client Know, Client Refused If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused Chronic Health Condition: Yes, No, Client Doesn’t Know, Client Refused
Head of Household HH Member 1 HH Member 2 HH Member 3 HH Member 4 Physical Disability: Yes, No, Client Know, Client Refused If yes, Expected to be of and indefinite duration and substantially impairs ability to live independently? Yes, No, Client Doesn’t Know, Client Refused Developmental Disability: Yes, No, Client Know, Client Refused If yes, Expected to substantially impair ability to live independently? Yes, No, Client Doesn’t Know, Client Refused Chronic Health Condition: Yes, No, Client Doesn’t Know, Client Refused
CT_HMIS_Statewide_Rapid_Rehousing_Emergency_Solutions_Grant_Family_Intake_Form_-_7.2_.docx