CT HMIS SNOFO DMHAS/DDaP/Street Outreach Discharge Form (To download this form, click here)

Applicant (Head of Household) Information:

First Name:                           Last Name:                           Client ID#:            

Project End Date:                 Case Manager Assigned to Discharge:                

 

Household Member Name HMIS ID# Date of Birth Gender Relationship to Head of Household
                                        Self

Cell Phone:                           Home Phone:                          

Work Phone:                                       

Email:                                           

Client Location:                                       

Housing Move – In Date:                            

Exit Destination Type:

HOMELESS SITUATION

  • Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station, airport or anywhere outside)
  • Safe Haven
  • Psychiatric Hospital or other psychiatric facility
  • Substance Abuse treatment facility or detox center
  • Hospital or other residential non-psychiatric medical facility
  • Jail, prison, or juvenile detention facility
  • Foster care or foster care group Home
  • Long-term care facility or Nursing Home
  • Transitional housing for homeless persons (including homeless youth)
  • Rental by client, no ongoing housing subsidy
  • Owned by client, no ongoing housing subsidy
  • Staying or living with family, temporary tenure (e.g., room, apartment, or house)
  • Staying or living with friends, temporary tenure (e.g., room, apartment, or house)
  • Hotel or Motel paid for without Emergency Shelter voucher
  • 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)
  • 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

Shared Housing Information:

Is this a Shared Housing Destination (separate leases)? Yes No

If Yes, Shared Housing Facilitated by: CAN Client

Non-Cash Benefit from any source? No Yes Client doesn’t know Client Prefers Not to Answer Data Not Collected

Non-cash benefits 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 2 HH Member 3 HH Member 4 HH Member 5
SNAP (Food Stamps)
Special Supplemental Nutrition Program for WIC
TANF Child Care Services
Client Doesn’t know

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 Disorder, Drug Disorder, 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, Data Not Collected

Translation Assistance:

Translation Assistance Needed? Yes No Client doesn’t know Client Prefers Not to Answer Data Not Collected

If yes, Preferred Language:                                         

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.

Income Type Head of Household HH Member 1 HH Member 2 HH Member 3
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 $
Private Disability Insurance N Y $ N Y $ N Y $ N Y $

DMHAS Specific Questions (*= Required Information):

*Discharge Reason:

  • AWOL for Inpatient only
  • Death
  • Evaluation Only
  • Incarcerated
  • Inpatient Discharge for Inpatient Medical Tx
  • Client Discontinued Tx
  • AMA
  • Left Against Advice
  • Moved out of area
  • Non-compliance with rules
  • Recovery Plan Completed
  • Released by Court
  • Discharged to New Service (Facility Concurs)
  • Other
  • Unknown

Service Type:

  • T1016 – Case Management with Client Face to Face
  • T116C – Case Management with Client By Telephone
  • T116B – Case Management with Collateral