CT HMIS Statewide SNOFO DMHAS Family Intake Form with DDaP FY2024
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CT HMIS SNOFO DMHAS/DDaP Street Outreach Family 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: _____________________
Applicant (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: ___________________________________________________________________________________________________________
Additional Household Member Demographics:
| Last Name | First Name | Date of Birth* | See codes below | Social Security Number* | Relationship to Head of Household* | Veteran (Y/N) |
Disabling Condition (Y/N) |
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| Middle Name | Suffix | Gender* | Race* | |||||||
| *Race: W– White; B- Black or African American; A- Asian; AI/AN– American Indian and Alaska Native; NH/PI– Native Hawaiian/ Pacific Islander; ME/NA– Middle Eastern or North African; NH/NL– Non-Hispanic/Non-Latin(a)(e)(o)(x) 🞎 H/L– Hispanic or Latin(a)(e)(o)(x) DK– Client Doesn’t Know; CR– Client prefers not to answer Additional Race and Ethnicity Detail: ________________________________________________________________________________ | ||||||||||
| *Gender: M – Man (Boy, if child); F– Woman (Girl, if child); T- Transgender; Q– Questioning; NB– Non-Binary; CSI– Culturally Specific Identity; DI– Different Identity; DK – Client Doesn’t Know; CR – Client prefers not to answer | ||||||||||
| *Relation to HOH: SP– Spouse; C– Child; SC– Child; GP– Grandparent; G– Guardian; OR– Other Relation; ONR– Other Non-Relative; U– Unknown; FC– Foster Child | ||||||||||
Client Location: ______________________________________
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
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
Translation Assistance Needed 🞎 Yes 🞎 No 🞎 Don’t Know 🞎 Client prefers not to answer
If ‘Yes,’ Preferred Language? ______________________
If “YES” Are you currently fleeing? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer 🞎 Data Not Collected
Non-Cash Benefit from any source? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
| Head of Household | HH Member 2 | HH Member 3 | HH Member 4 | HH Member 5 | |
| Check which applies | Check which applies | Check which applies | Check which applies | Check which applies | |
| (SNAP) Food Stamps | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| Special Supplemental Nutrition Program for WIC | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| TANF Child Care Services | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| TANF Transportation | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| Other TANF-Funded Services | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| Client Doesn’t know | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| Client prefers not to answer | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
| Other (Please Specify): | 🞎 | 🞎 | 🞎 | 🞎 | 🞎 |
Covered by Health Insurance: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
Connection with SOAR: 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
Disabling Conditions (All Clients)
| Head of Household | HH Member 2 | HH Member 3 | HH Member 4 | HH Member 5 | |
| Disabling Condition (All Adults) No, Yes, Client Doesn’t Know, Client prefers not to answer, Data Not Collected |
N/A | ||||
|
Physical Disability (All Clients) 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 | |||||
|
Developmental Disability (All Clients) No, Yes, Client Doesn’t Know, Client prefers not to answer, Data Not Collected |
|||||
|
Chronic Health Condition (All Clients) 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 (All Clients) No, Yes, Client Doesn’t Know, Client prefers not to answer, Data Not Collected |
|||||
|
Mental Health Disorder (All Clients) 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 | |||||
|
Substance Abuse Disorder (All Clients) No, Alcohol Abuse, Drug Abuse, Both Alcohol and Drug, 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 |
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 for each member):
| Head of Household (HOH) | Member 2 | Member 3 | Member 4 | Member 5 |
|
🞎 MEDICAID 🞎 MEDICARE 🞎 State Children’s Health Insurance Program 🞎 Veteran’s Health Administration (VHA) 🞎 Employer-Provided Health Insurance 🞎 Health Insurance obtained through COBRA 🞎 State Health Insurance for Adults 🞎 Private Pay Health Insurance 🞎 Indian Health Services Program 🞎 Other If Other, Specify: ____________________________ |
🞎 MEDICAID 🞎 MEDICARE 🞎 State Children’s Health Insurance Program 🞎 Veteran’s Health Administration (VHA) 🞎 Employer-Provided Health Insurance 🞎 Health Insurance obtained through COBRA 🞎 State Health Insurance for Adults 🞎 Private Pay Health Insurance 🞎 Indian Health Services Program 🞎 Other If Other, Specify: ___________________________ |
🞎 MEDICAID 🞎 MEDICARE 🞎 State Children’s Health Insurance Program 🞎 Veteran’s Health Administration (VHA) 🞎 Employer-Provided Health Insurance 🞎 Health Insurance obtained through COBRA 🞎 State Health Insurance for Adults 🞎 Private Pay Health Insurance 🞎 Indian Health Services Program 🞎 Other If Other, Specify: ___________________________ |
🞎 MEDICAID 🞎 MEDICARE 🞎 State Children’s Health Insurance Program 🞎 Veteran’s Health Administration (VHA) 🞎 Employer-Provided Health Insurance 🞎 Health Insurance obtained through COBRA 🞎 State Health Insurance for Adults 🞎 Private Pay Health Insurance 🞎 Indian Health Services Program 🞎 Other If Other, Specify: ___________________________ |
🞎 MEDICAID 🞎 MEDICARE 🞎 State Children’s Health Insurance Program 🞎 Veteran’s Health Administration (VHA) 🞎 Employer-Provided Health Insurance 🞎 Health Insurance obtained through COBRA 🞎 State Health Insurance for Adults 🞎 Private Pay Health Insurance 🞎 Indian Health Services Program 🞎 Other If Other, Specify: ___________________________ |
Income
Income received from any source (HOH and Adults only)? 🞎 No 🞎 Yes 🞎 Client doesn’t know 🞎 Client prefers not to answer🞎 Data Not Collected
*Note: Income received by or on behalf of a minor child should be recorded as part of the household income under the Head of Household.
| Head of Household | HH Member 1 | HH Member 2 | HH Member 3 | |
| Income Type | Monthly Amount | Monthly Amount | Monthly Amount | Monthly Amount |
| Unemployment Insurance | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Earned/Employed Income | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Supplemental Security Income (SSI) | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Social Security Disability Insurance (SSDI) | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| VA Service-Connected Disability Compensation | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Private Disability Insurance | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Retirement Income from Social Security | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| General Assistance (GA) | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Temporary Assistance for Needy Families (TANF) | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| VA Non-Service-Connected Disability Pension | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Pension or Retirement income from a former job | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Child Support | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Alimony or other spousal support | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| Worker’s Compensation | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
|
Other Source Specify: |
🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ | 🞎 N 🞎 Y $ |
| CLIENT INCOME TOTAL: | $ | $ | $ | $ |
DMHAS Specific Question (*= 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 |
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: ____________________________________________________________________________________________________________________
City: _______________________________________________ State: _____________________________________ Zip Code: _________________________
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 🞎 Client prefers not to answer
*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 🞎 Client prefers not to answer 🞎 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 Intervention
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
Additional notes: