Agency s LOGO Universal Intake Form HMIS CLIENT ID# Fill-in after ServicePoint Entry Intake/Entry Date Month / Day / Year ME OF HEAD OF HOUSEHOLD (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not know Client refused to provide First Name Middle Name Last Name Suffix SSN Veteran Status Relationship (to HoH) SELF Number in Household: Use a separate HH Member Supplemental page for each additional HH member Date of Birth Gender Male Female Transgender: M to F Transgender: F to M Doesn t identify as male, female or transgender Ethnicity n-hispanic/latino Hispanic/Latino Primary Race Indian or Other Secondary Race (Leave Blank if None) Indian or Other Primary Language Felony Conviction: English Spanish Other, specify: Domestic Violence Victim/Survivor (If Yes) how long ago was the last incident? Within the past 3 months 3-6 months ago 6-12 months ago More than a year ago Client Doesn t Know (If Yes) are you currently fleeing? Client Does Not Know Disabling Conditions: Continue to Disability Assessment
DISABILITY ASSESSMENT Client Name: Disability Type (If Yes) Start Date Currently receiving Services or Treatment? Above Condition going to be long term? Disability Determination Documentation of disability and severity on file Alcohol Abuse Drug Abuse Alcohol and Drug Abuse Chronic Health Condition HIV/AIDS Mental Health Problem Developmental Disability Physical Disability Client Doesn t Know Client Doesn t Know Client Doesn t Know Client Doesn t Know Client Doesn t Know Client Doesn t Know Client Doesn t Know Client Doesn t Know
LAST PERMANENT ADDRESS (LAST PLACE CLIENT LIVED FOR 90 DAYS OR MORE; CITY & ZIP CODE REQUIRED) Previous Address Apt # City, Township Start Date State Zip End Date Phone Number Emergency Contact Name & Relationship: Client Does Not Know Alternate Phone Emergency Contact Phone: RESIDENCE PRIOR TO PROJECT ENTRY: (FOUND ON THE CHRONIC HOMELESS ASSESSMENT) Literally Homeless Place not meant for human habitation Emergency Shelter (includes hotel/motel paid for with agency voucher) Safe Haven Interim Housing Institutional Setting Foster care home or foster care group home Hospital or other residential non-psychiatric medical facility Jail, prison, or juvenile detention facility Long term care facility or nursing home Psychiatric Hospital or Facility Substance Abuse Treatment Facility or detox center LENGTH OF STAY (AT PRIOR RESIDENCE) (FOUND ON THE CHRONIC HOMELESS ASSESSMENT) One Day or Less Two Days to One Week More Than One Week but Less Than One Month One to Three Months Transitional & Permanent Housing Situation Hotel or motel paid for without emergency shelter voucher Owned by client, NO ongoing housing subsidy Owned by client, with ongoing housing subsidy Permanent Housing for formerly homeless persons Rental by client, NO ongoing housing subsidy Rental by client, with VASH housing subsidy Rental by client with GPD TIP subsidy Rental by client, with other ongoing housing subsidy Residential Project/halfway house with NO homeless criteria Staying or living with a family member Staying or living with a friend Transitional Housing for homeless persons (including homeless youth) Client does not know More than three months, but less than one year One Year or Longer Client Does Not Know TIME ON STREETS, IN AN EMERGENCY SHELTER, OR SAFE HAVEN (FOUND ON THE CHRONIC HOMELESS ASSESSMENT) For all projects except Emergency Shelter, Street Outreach and Safe Haven: If the Residence Prior to Project Entry selection is under : Complete the Chronic Questions Below the Institutional Setting header then was the client there : Skip to Last Permanent Address LESS than 90 days? If the Residence Prior to Project Entry selection is under the Transitional & Permanent Housing Situation header, then was the client there MORE than 7 days? : Skip to Last Permanent Address : Complete the Chronic Questions Below CHRONIC QUESTIONS: Required for Emergency Shelter, Street Outreach, Safe Haven, or depending on answers above Entering from Street, Emergency shelter or safe haven? Client Doesn t Know Approximate Date this episode of homelessness began? / / Regardless of where they stayed last night -- Number of times the client has been homeless on the streets, in ES, or SH in the past three years including today. Never in 3 Years One Time Two Times Three Times Four or more times Client Doesn t Know Total number of months on the street, in ES or SH in the past 3 years: months HOUSEHOLD INCOME Does the household have any current income? Client Does Not Know
If No, answer the following question and move on to Household Income for AMI Below: Do you need assistance in applying for cash benefits? If Yes: Please indicate in each source if the household receives the income, and if they do, the household member receiving the income, the monthly amount (to the nearest dollar) of each source, and the income start date. Earned Income HH Member Amount Start Date HH Member Amount Start Date If Yes: $ $ $ $ Social Security Disability Income If Yes: $ $ Worker s Compensation If Yes: $ $ Child Support If Yes: $ $ Retirement Income from Social Security If Yes: $ $ Unemployment Insurance If Yes: $ $ VA Service Connected If Yes: $ $ VA Non-Service Connected If Yes: $ $ Alimony or Other Spousal Support If Yes: $ $ Temporary Assistance for Needy Families (TANF) If Yes: $ $ SSI: Supplemental Security Income If Yes: $ $ Private Disability Insurance If Yes: $ $ General Assistance If Yes: $ $ Pension from a former job If Yes: $ $ Other Source (specify): If Yes: $ $ For Each Individual Household Member with income record their individual total income from all sources below Household Member Total Monthly Income Household Member Total Monthly Income
TOTAL MONTHLY HOUSEHOLD INCOME $ NUMBER OF HOUSEHOLD MEMBERS FY2016 AREA MEDIAN INCOME (AMI) Household Size 1 2 3 4 5 6 7 8 30% AMI $1,346 $1,538 $1,729 $1,921 $2,075 $2,229 $2,383 $2,538 50% AMI $2,246 $2,567 $2,888 $3,204 $3,463 $3,721 $3,975 $4,233 80% AMI $3,588 $4,100 $4,613 $5,125 $5,538 $5,946 $6,358 $6,767 100% AMI $4,492 $5,133 $5,775 $6,408 $6,925 $7,442 $7,950 $8,467 TOTAL MONTHLY HOUSEHOLD INCOME AS PERCENTAGE OF AMI: BELOW 30% 30%-49% 50%-79% 80%-99% 100% and above 50% AND ABOVE NON-CASH BENEFITS Does the household currently receive any Non-Cash Benefits? Client Does Not Know Please indicate which of the following non-cash benefits have you received over the last 30 days. (You may use All if all household members receive the benefit) Food stamps or money for food on a benefits card (If yes, amount of benefit) Amount (optional): $ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) TANF child care services TANF transportation services Other TANF-Funded Services Section 8, Public Housing, or other rental assistance Temporary rental assistance LIHEAP Other Source (specify): If No - Do you need assistance in applying for non-cash benefits?
COVERED BY HEALTH INSURANCE Do household members currently have health insurance? Client Does Not Know Complete the following (You may use All if all household members receive the benefit) Medicaid Medicare Illinois All Kids (State Children s Health Insurance Program) Veteran s Administration Medical Services Employer Provided Health Insurance Health Insurance obtained through COBRA Private Pay Health Insurance If No, Reason? Applied; decision pending Applied; client not eligible Client did not apply Insurance type N/A for this client All Applicants Must Sign Below By signing below I attest that the information I have provided for eligibility and intake is a true and accurate account of the current situation, income and household. Client signature: Date: Agency Representative Name (print): Agency Representative Signature: Date:
Head of Household Name: Universal Intake HH Member Supplemental HMIS CLIENT ID# INTAKE DATE Month / Day / Year ME OF MEMBER OF HOUSEHOLD (first, middle, last name, suffix (e.g., Jr, Sr, III)) Client does not know Client refused to provide First Name Middle Name Last Name Suffix SSN Relationship (to HoH) HoH s Child HoH s Spouse/Partner HoH s Other Relation Other: Non-Relation Date of Birth Gender Male Female Transgender: M to F Transgender: F to M Doesn t identify as male, female or transgender Ethnicity n-hispanic/latino Hispanic/Latino Primary Race Indian or Other Secondary Race (Leave Blank if None) Indian or Other Veteran Status Primary Language Felony Conviction: English Spanish Other, specify: Domestic Violence Victim/Survivor (If Yes) how long ago was the last incident? Within the past 3 months 3-6 months ago 6-12 months ago More than a year ago Client Doesn t Know (If Yes) are you currently fleeing? Client Does Not Know Disabling Conditions: Continue to Disability Assessment (use a copy of the disability assessment on page 2)