CT HMIS SNOFO HMIS Individual Intake Form FY2024
CT HMIS SNOFO Outreach DMHAS Individual Intake Form
Instructions: The System Entry Intake is completed if a household cannot be diverted from homelessness and needs to access services in the homeless system. The interviewer should have access to the information captured during the Diversion Screening (if it was conducted) as well as shelter stay history from HMIS (if there is a shelter history). The Intake assesses basic needs and captures HMIS required data elements for program entries. The interviewer should just confirm and update it as needed.
Project Start Date: _____________________
Head of Household Information:
First Name: ________________________________________________ Last Name: __________________________________________________
Middle Name: ______________________________________________ Suffix: _______________________________________________________
Name Data Quality: 🞎 Full Name Reported 🞎 Partial, Street Name, or Code Name reported 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
Date of Birth: _________/_______/_________ 🞎 Full DOB Reported 🞎 Approximate or Partial DOB Reported 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
Social Security Number: __________-________-__________
🞎 Full SSN Reported 🞎 Approximate or Partial SSN Reported 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
Gender: 🞎 Man (Boy, if child) 🞎 Woman (Girl, if child) 🞎 Transgender 🞎 Questioning 🞎 Non-Binary 🞎 Culturally Specific Identity (e.g., Two-Spirit) 🞎 Different Identity IF Different Identity Please Specify ______________ or 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
Primary Language: 🞎 English 🞎 Spanish 🞎 French 🞎 Portuguese 🞎 Other 🞎 Client Doesn’t Know If Other, please specify: ______________________
Relationship to HOH: 🞎 Self 🞎 Spouse 🞎 Child 🞎 Step-Child 🞎 Grandparent 🞎 Guardian 🞎 Other Relative 🞎 Other Non-Relative 🞎 Grandchild
🞎 Foster-Child
Race & Ethnicity: 🞎 White 🞎 Black, African American or African 🞎 Asian or Asian American 🞎 American Indian, Alaska Native, or Indigenous 🞎 Native Hawaiian or Pacific Islander 🞎 Middle Eastern or North African 🞎 Client Doesn’t Know 🞎 Non-Hispanic/Non-Latin(a)(e)(o)(x) 🞎 Hispanic or Latin(a)(e)(o)(x) 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
Additional Race and Ethnicity Detail: ________________________________________________________________________________________________
Veteran Status: Have you ever been on active duty in the U.S. Military? 🞎 Yes 🞎 No 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Cell Phone: ___________________________________________Home Phone: ________________________________________________
Work Phone: _____________________________________________________________________________________________________
Email: ___________________________________________________________________________________________________________
Client Location: ______________________________________ (Agency Provider Name will auto populate in HMIS)
Disabling Condition: 🞎 No 🞎 Yes 🞎 Client Doesn’t Know 🞎 Client prefers not to answer 🞎 Data Not Collected
Type of Residence (Residence Prior to Program entry):
🞎 Emergency shelter, including hotel or motel paid for with emergency shelter voucher, Host Home shelter
🞎 Place not meant for habitation
🞎 Safe Haven
INSTITUTIONAL SITUATION
🞎 Foster care 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 other psychiatric facility
🞎 Substance Abuse treatment facility or detox
center
TRANSITIONAL HOUSING SITUATION
🞎 Hotel / Motel paid without ES voucher
🞎 Staying or living in a family, member’s room, apartment, or house
🞎 Staying or living in a family member’s room, apartment, or house
🞎 Transitional housing for homeless persons (including youth)
PERMANENT HOUSING SITUATION
🞎 Rental by client no ongoing housing subsidy
🞎 Rental by client, with ongoing housing
Subsidy
IF Rental by client, with ongoing housing
Subsidy is Checked, Please select Subsidy from List:
🞎 GPD TIP housing subsidy
🞎 VASH housing subsidy
🞎 RRH or equivalent subsidy
🞎 HCV voucher (tenant or project based) (not dedicated)
🞎 Public housing unit
🞎 Rental by client, with other ongoing housing subsidy
🞎 Emergency Housing Voucher
🞎 Family Unification Program Voucher (FUP)
🞎 Foster Youth to Independence Initiative (FYI)
🞎 Permanent Supportive Housing
🞎 Other permanent housing dedicated for formerly homeless persons
🞎 Owned by client, no ongoing housing subsidy
🞎 Owned by client, with ongoing housing subsidy
OTHER
🞎 Client doesn’t know
🞎 Client prefers not to answer
🞎 Data Not Collected
Length of stay in the prior living situation
🞎 One night or less
🞎 Two days to six nights
🞎 One week or more, but less than one month
🞎 One month or more, but less than 90 days
🞎 90 days or more, but less than one year
🞎 One year or longer 🞎 Client prefers not to answer
🞎 Client doesn’t know
🞎 Data Not Collected
Approximate Date Homeless Started: ~3.917 – Record the actual or approximate date this homeless situation began (i.e., the beginning of the continuous period of homelessness on the streets, in emergency shelters, in safe havens, or moving back and forth between those places).
Approximate Date Homelessness Started: _______/_________/__________
(Regardless of where they stayed last night) Number of times the client has been 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
🞎 Client prefers not to answer
🞎 Data Not Collected
Total number of months homeless on the streets, in ES, or SH in the past three years:
🞎 One Month (this time is the first month)
🞎 2
🞎 3
🞎 4
🞎 5
🞎 6
🞎 7
🞎 8
🞎 9
🞎 10
🞎 11
🞎 12
🞎 More than 12 Months
🞎 Client doesn’t know
🞎 Client prefers not to answer
🞎 Data Not Collected
Domestic Violence Survivor? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If “YES” When experience occurred?
🞎 Within the past three months
🞎 Three to six months ago (excluding six months exactly)
🞎 From six months to one year ago (excluding one year exactly)
🞎 One year ago, or more
🞎 Client doesn’t know
🞎 Client prefers not to answer
🞎 Data Not Collected
If “YES” Are you currently fleeing? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Translation Assistance Needed 🞎 Yes 🞎 No 🞎 Don’t Know 🞎 Client prefers not to answer
If ‘Yes,’ Preferred Language? ______________________
Non-Cash Benefit from any source? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If yes, Non-cash benefit source is required. Check those that apply:
🞎 Supplemental Nutrition Assistance Program (SNAP) (Previously known as Food Stamps)
🞎 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
🞎 TANF Child Care Services
🞎 TANF Transportation services
🞎 Other TANF-funded services
🞎 Other Source : Specify if Other: ______________________________________________________________
Covered by Health Insurance: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
Sexual Orientation:
🞎 Heterosexual 🞎 Gay 🞎 Lesbian 🞎 Bisexual 🞎 Questioning/Unsure 🞎Other 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
Disabling Conditions
Substance Abuse Disorder: 🞎 No 🞎 Alcohol Abuse 🞎 Drug Abuse 🞎 Both Alcohol and Drug Abuse 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? 🞎 No 🞎 Yes 🞎 Client doesn’t know
🞎 Client prefers not to answer 🞎 Data Not Collected
Physical Disability: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? 🞎 Yes 🞎 No 🞎 Client Doesn’t Know
🞎 Client prefers not to answer
Developmental Disability: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Chronic Health Condition: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? 🞎 No 🞎 Yes 🞎 Client doesn’t know
🞎 Client prefers not to answer 🞎 Data Not Collected
HIV/AIDS: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Mental Health Disorder: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
If yes, expected to be of long-continued and indefinite duration and substantially impairs ability to live independently? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Prior Zip Code (Numbers ONLY): _________________________
Shared Housing Information:
(Shared housing means clients will be on separate leases or living as roommates. Not clients living together as a couple):
Would the client accept Shared Housing if offered? 🞎 Yes 🞎 No
Health Insurance (select which applies):
| 🞎 MEDICAID | 🞎 State Health Insurance for Adults |
| 🞎 MEDICARE | 🞎 Private Pay Health Insurance |
| 🞎 State Children’s Health Insurance Program | 🞎 Indian Health Services Program |
| 🞎 Veteran’s Health Administration (VHA) | 🞎 Other |
| 🞎 Employer-Provided Health Insurance | If Other, Specify: _____________________________ |
| 🞎 Health Insurance obtained through COBRA |
Income received from any source? 🞎 Yes 🞎 No 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
| Income Type | Monthly Amount | Income Type | Monthly Amount |
| Unemployment Insurance | 🞎 N 🞎 Y $ | VA Non-Service-Connected Disability Pension | 🞎 N 🞎 Y $ |
| Earned/Employed Income | 🞎 N 🞎 Y $ | Pension or Retirement income from a former job | 🞎 N 🞎 Y $ |
| Supplemental Security Income (SSI) | 🞎 N 🞎 Y $ | Child Support | 🞎 N 🞎 Y $ |
| Social Security Disability Insurance (SSDI) | 🞎 N 🞎 Y $ | Alimony or other spousal support | 🞎 N 🞎 Y $ |
| VA Service-Connected Disability Compensation | 🞎 N 🞎 Y $ | Worker’s Compensation | 🞎 N 🞎 Y $ |
| Private Disability Insurance | 🞎 N 🞎 Y $ | Other Source
Specify: |
🞎 N 🞎 Y $ |
| Retirement Income from Social Security | 🞎 N 🞎 Y $ | ||
| General Assistance (GA) | 🞎 N 🞎 Y $ | ||
| Temporary Assistance for Needy Families (TANF) | 🞎 N 🞎 Y $ | Client Income Total | $ |
DMHAS Specific Questions (*= Required Information):
*Primary Language Spoken:
🞎 English
🞎 Spanish
🞎 Chinese
🞎 Russian
🞎 Arabic
🞎 Portuguese
🞎 Bengali
🞎 French
🞎 Malay, Indonesian
🞎 German
🞎 Japanese
🞎 Farsi (Persian)
🞎 Urdu
🞎 Punjabi
🞎 Vietnamese
🞎 Tamil
🞎 Javanese
🞎 Korean
🞎 Turkish
🞎 Telugu
🞎 Marathi
🞎 Italian
🞎 Thai
🞎 Burmese
🞎 Kannada
🞎 Gujarati
🞎 Polish
🞎 Hindi
🞎 Cantonese
🞎 Haitian Creole
🞎 Unknown
🞎 Other
Religion:
🞎 Protestant
🞎 Catholic
🞎 Jewish
🞎 Muslim
🞎 Buddhist
🞎 Mormon
🞎 Orthodox Christian
🞎 Hindu
🞎 Pentecostal
🞎 None
🞎 Other
🞎 Unknown
*Marital Status:
🞎 Never Married
🞎 Married
🞎 Separated
🞎 Divorced/Annulled
🞎 Widowed
🞎 Civil Union
🞎 Other
🞎 Unknown
*Primary Referral Source:
🞎 Self
🞎 Family/Friend
🞎 Mental Health Provider
🞎 Substance Abuse Provider
🞎 Medical Health Practitioner
🞎 School
🞎 Employer/Supervisor
🞎 Employee Assistance Program
🞎 Clergy/Church/Synagogue
🞎 Dept. of Children and Families
🞎 Dept. of Social Services
🞎 Dept. of Developmental Disabilities
🞎 Other Community Referral
🞎 Court Order
🞎 Probation/Parole
🞎 Police
🞎 Shelter
🞎 Dept. of Corrections
🞎 Other
🞎 Unknown
Pregnancy Status: 🞎 No 🞎 Yes 🞎 Client Doesn’t Know 🞎 Client prefers not to answer 🞎 Data Not Collected
*DMHAS – Insurance Type
| Insurance Type 1 | Insurance Policy Number
(**- REQUIRED) |
Insurance Policy Start Date | Insurance Policy End Date | |
| YES / NO* | ||||
| No Health Insurance | ||||
| Other private insurance | ||||
| Medicare | ||||
| Champus | ||||
| **Medicaid Husky C (Insurance Policy Number Required) | ||||
| HMO (including Managed Medicaid) | ||||
| GA-SAGA | ||||
| ATR-Access to Recovery | ||||
| Self-Pay | ||||
| Medicaid LIA Husky D | ||||
| Medicare Part A | ||||
| Medicare Part B | ||||
| Money Follows the Person (MFP) | ||||
| Nursing Home Waiver | ||||
| **Medicaid BHH (Insurance Policy Number Required) | ||||
| **Medicaid- Husky A (Insurance Policy Number Required) | ||||
| Medicaid BHH – Waiver | ||||
| Other | ||||
| Unknown |
Veteran Information:
DD214 Order Date: ___________/______________/______________ DD214 Receive Date: __________/______________/____________
Service Connected Disability: 🞎 Yes 🞎 No
*Branch of military: 🞎 Air Force 🞎 Army 🞎 Marines 🞎 Navy 🞎 Coast Guard 🞎Space Force 🞎 Client Doesn’t Know 🞎 Client prefers not to answer 🞎 Other
Reserves: 🞎 Yes 🞎 No
*Discharge status: 🞎 Honorable 🞎 General under Honorable Conditions 🞎 Under Other than Honorable Conditions 🞎 Bad Conduct 🞎 Dishonorable
🞎 Uncharacterized 🞎 Don’t Know 🞎 Refused
*Date Entered Service: ___________/____________/______________ *Date Separated Service: _________/______________/____________
Months of Active Duty: _______________________________ Campaign Badge Veteran: 🞎 Yes 🞎 No
Stand Down Event: 🞎 Yes 🞎 No
Serve in a War Zone: 🞎 Yes 🞎 No 🞎 Client Doesn’t Know 🞎 Client prefers not to answer
If YES, please select the War Zone Name: 🞎 Afghanistan 🞎 China, Burma, India 🞎 Don’t Know 🞎 Europe 🞎 Iraq 🞎 Korea 🞎 Laos and Cambodia 🞎 North Africa
🞎 Other 🞎 Persian Gulf 🞎 Refused 🞎 South China Sea 🞎 South Pacific 🞎 Vietnam
*Months Served in a Warzone: ______________________ *If Yes, Received Friendly or Hostile Fire: ___________________
*Theatre of Operations: 🞎 World War II 🞎 Korean War 🞎 Vietnam War 🞎 Persian Gulf War (Operation Desert Storm) 🞎 Afghanistan (Operation Enduring Freedom) 🞎 Iraq (Operation Iraqi Freedom) 🞎 Iraq (Operation New Dawn) 🞎 Other Peace-keeping Operations or Military Interventions
Current Living Situation: All street outreach projects are expected to record every contact made with each client by recording their Current Living Situation, including when the Project Start Date, Prior Living Situation or Date of Engagement is recorded on the same day. There may or may not be a contact made at project exit.
Information Date: _____________ Project: _____________________________________________________
HOMELESS SITUATION
🞎 Emergency shelter, including hotel or motel paid for with emergency shelter voucher, Host Home shelter
🞎 Place not meant for habitation
🞎 Safe Haven
INSTITUTIONAL SITUATION
🞎 Foster care 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 other psychiatric facility
🞎 Substance Abuse treatment facility or detox
center
TRANSITIONAL HOUSING SITUATION
🞎 Hotel / Motel paid without ES voucher
🞎 Staying or living in a family, member’s room, apartment, or house
🞎 Staying or living in a family member’s room, apartment, or house
🞎 Transitional housing for homeless persons (including youth)
PERMANENT HOUSING SITUATION
🞎 Rental by client no ongoing housing subsidy
🞎 Rental by client, with ongoing housing
Subsidy
IF Rental by client, with ongoing housing
Subsidy is Checked, Please select Subsidy from List:
🞎 GPD TIP housing subsidy
🞎 VASH housing subsidy
🞎 RRH or equivalent subsidy
🞎 HCV voucher (tenant or project based) (not dedicated)
🞎 Public housing unit
🞎 Rental by client, with other ongoing housing subsidy
🞎 Emergency Housing Voucher
🞎 Family Unification Program Voucher (FUP)
🞎 Foster Youth to Independence Initiative (FYI)
🞎 Permanent Supportive Housing
🞎 Other permanent housing dedicated for formerly homeless persons
🞎 Owned by client, no ongoing housing subsidy
🞎 Owned by client, with ongoing housing subsidy
OTHER
🞎 Client doesn’t know
🞎 Client prefers not to answer
🞎 Data Not Collected
Service Type
🞎 T1006 – Family Counseling
🞎 T1016 – Case Management with Client Face to Face
🞎 T106B – Family Counseling w/o patient
🞎 T116A – Case Management Audio and Visual with Client
🞎 T116B – Case Management with Collateral
🞎 T116C – Case Management with Client by Telephone
Last Permanent Address (Head of Household and All Adults): Required for DDaP
Address Data Quality: 🞎 Full Address Reported 🞎 Incomplete or Estimated Address Reported 🞎 Client doesn’t know 🞎 Client prefers not to answer
Street Address: (If Homeless Just Enter Homeless)_____________________________________________________________________________________
City: _______________________________________________ State: _____________________________________ Zip Code: _________________________
Additional notes: