HMIS Annual Assessment/Update Form
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- Milo Clyde Harrison
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1 Name/Identification and Contact Information: HMIS consent form signed? Legal First Name: Legal Last Name: Project Name: Case Manager: Middle Name: Suffix: Project Entry Date: / / Date of Assessment: / / Income Cash Sources: Income Source (Check all that apply): financial resources Earned Income Unemployment Insurance Supplemental Security Income (SSI) Social Security Disability (SSDI) VA Service-Connected Disability Compensation Private Disability Insurance Workers Compensation General Assistance (GA or GR) Retirement Income from Social Security VA n-service-connected Disability Pension Pension from a former job Child Support Alimony or other spousal support Other Source TANF Stated Income: Pay Interval: Every Other Weekly Week Twice A Month Monthly Quarterly Yearly Income n-cash Benefits: n-cash Benefits (Check all that apply): ne Food Stamps (CalFresh) CalWorks Child Care Temporary Rental Assistance Amount: CalWorks Transportation Section 8 or Rental Assistance Medically Needy WIC Other CalWorks-Funded Services Other Amount: Health Insurance (Check all that apply): Health Insurance Medi-Cal Employer Provided Health Ins. MEDICARE COBRA Health Ins. State Children s Health Ins. Private Health Ins. VA Medical Services Revised 8/3/2016 Page 1
2 Assessment Questions All clients, required questions are shaded Question Check One Answer Comments 1. Is this an update or annual assessment? Project Update Project Annual Assessment 2. Do you have a physical disability? 2a. Do you expect this to be of long continued and (Required if question 2 is ) 2b. Do you have documentation of the disability and (Required if question 2 is ) 2c. Are you currently receiving services/treatment for (Required if question 2 is ) 3. Do you have a developmental disability? 3a. Do you expect this to be of long continued and (Required if question 3 is ) 3b. Do you have documentation of the disability and (Required if question 3 is ) 3c. Are you currently receiving services/treatment for (Required if question 3 is ) 4. Do you have a chronic health condition? 4a. Do you expect this to be of long continued and (Required if question 4 is ) 4b. Do you have documentation of the disability and (Required if question 4 is ) 4c. Are you currently receiving services/treatment for (Required if question 4 is ) 5. Have you been diagnosed with AIDS or have you tested positive for HIV? Revised 8/3/2016 Page 2
3 5a. Do you expect this to substantially impair your ability (Required if question 5 is ) 5b. Do you have documentation of the disability and (Required if question 5 is ) 5c. Are you currently receiving services/treatment for (Required if question 5 is ) 6. Do you feel you currently have a mental health problem? 6a. Do you expect this to be of long continued and (Required if question 6 is ) 6b. Do you have documentation of the disability and (Required if question 6 is ) 6c. Are you currently receiving services/treatment for (Required if question 6 is ) 6d. How was the mental health condition confirmed? (Required for PATH only if question 6 is ) 6e. Does the client have a serious mental illness? If so, how was it confirmed? (Required for PATH only if question 6 is ) 7. Do you have an alcohol and/or drug abuse problem? Alcohol Drug Both 7a. Do you expect this to be of long continued and (Required if question 7 is Alcohol, Drug, or Both ) 7b. Do you have documentation of the disability and (Required if question 7 is Alcohol, Drug, or Both ) Unconfirmed; presumptive or self-report Confirmed through assessment and clinical evaluation Confirmed by prior evaluation or clinical records Unconfirmed; presumptive or self-report Confirmed through assessment and clinical evaluation Confirmed by prior evaluation or clinical records Revised 8/3/2016 Page 3
4 7c. Are you currently receiving services/treatment for (Required if question 7 is Alcohol, Drug, or Both ) 7d. How was the substance abuse condition confirmed? (Required for PATH only if question 7 is Alcohol, Drug, or Both ) 8. Have you been a victim of domestic violence or a victim of intimate partner violence? 8a. When did this experience occur? (Required if question 8 is ) 8b. Are you currently fleeing? (Required if question 8 is ) Unconfirmed; presumptive or self-report Confirmed through assessment and clinical evaluation Confirmed by prior evaluation or clinical records Within the past three months Three to six months ago (excluding six months exactly) From six to twelve months ago (excluding one year exactly) More than a year ago HOPWA For HOPWA Funded Projects, Required questions are shaded 9. Is the client receiving Public HIV/AIDS Medical Assistance? 9a. If, Reason for not receiving HIV/AIDS Medical Assistance. (FOR HOPWA: Required if question 9 is ) 10. Is client receiving AIDS Drug Assistance Program (ADAP)? 10a. If, Reason for not receiving AIDS Drug Assistance Program (ADAP). (FOR HOPWA: Required if question 10 is ) 11. Is client receiving Medi-Cal? Revised 8/3/2016 Page 4
5 11a. If, Reason for not receiving Medi-Cal (FOR HOPWA: Required if question 11 is ) 12. Is client receiving Medicare? 12a. If, Reason for not receiving Medicare (FOR HOPWA: Required if question 12 is ) 13. Is client receiving State Children s Health Insurance Program? 13a. If, Reason for not receiving State Children s Health Insurance Program (FOR HOPWA: Required if question 13 is ) 14. Is client receiving VA Medical Services? 14a. If, Reason for not receiving VA Medical Services (FOR HOPWA: Required if question 14 is ) 15. Is client receiving Employer Provided Health Insurance? 15a. Reason for not receiving Employer Provided Health Insurance (FOR HOPWA: Required if question 15 is ) 16. Is client receiving Health Insurance through COBRA? 16a. If, Reason for not receiving Health Insurance through COBRA (HOPWA: Required if question 16 is ) Revised 8/3/2016 Page 5
6 17. Is client receiving Private Pay Health Insurance? 17a. If, Reason for not receiving Private Pay Health Insurance (HOPWA: Required if question 17 is ) 18. T-Cell (CD4) Count Available (Required for HOPWA) 18a. T-Cell Count (Required for HOPWA projects if ) 18b. How was the data obtained? (Required for HOPWA projects) 19. Viral Load Available (Required for HOPWA projects) 19a. Viral Load (HOPWA: Required if question 19 is ) 19b. How was the data obtained? (HOPWA: Required if question 19 is ) (Enter a number ) Medical Report Other Client Report (Enter a number ) Medical Report Other Client Report Client Signature Site Date Agency Staff Signature Site Date DO NOT WRITE IN BOX BELOW DATA ENTRY PERSONNEL ONLY (Optional): Date entered into HMIS: / / Question Answer Initials of Staff completion Was the hard copy intake form completely filled out correctly? Comments Staff Name (verifying completion of Data Entry): Revised 8/3/2016 Page 6
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