ࡱ> }|a 7jbjb11 [[1""""J#47#####i$i$i$ 7777777,{9R;:7i$e$i$i$i$:7c&##O7c&c&c&i$L## 7c&4"i$ 7c&c&57~# "$H67 e707\6<c&<(7c&DB BServicePoint 4.04 SAMPLE HOUSEHOLDS Intake Form (rev 03/07) (Data elements in brown are optional for HUD programs but required for some San Diego City/County funded programs) **(SD) denotes selections that correspond to city/county reports and NOT the HUD APR** (PLEASE PRINT) Profile First Name:________________________ MI:_____ Last Name:___________________________________ Suffix:___________ SS #: _______-_____-_______ + Household Relationships- (All other adults and children in household) Household Type: Couple (parent & friend) ____ Couple without children ____ Foster Parent(s) ____ Grandparent(s) and child ____ Non-Custodial Caregiver(s)____ Non-Custodial Parent(s) ____ Single Parent____ Two Parent____ Other _______________________ 1. First Name: ___________________________ Last Name: ______________________________ SS#: _______-______-_______ Date of Birth: ____/____/_____ Gender: M____ F____ Race:____________________ Ethnicity: Hispanic/Latino____ Other____ Relationship to Primary Client:______________________ 2. First Name: ___________________________ Last Name: ______________________________ SS#: _______-______-_______ Date of Birth: ____/____/_____ Gender: M____ F____ Race:____________________ Ethnicity: Hispanic/Latino____ Other____ Relationship to Primary Client:______________________ 3. First Name: ___________________________ Last Name: ______________________________ SS#: _______-______-_______ Date of Birth: ____/____/_____ Gender: M____ F____ Race:____________________ Ethnicity: Hispanic/Latino____ Other____ Relationship to Primary Client:______________________ 4. First Name: ___________________________ Last Name: ______________________________ SS#: _______-______-_______ Date of Birth: ____/____/_____ Gender: M____ F____ Race:____________________ Ethnicity: Hispanic/Latino____ Other____ Relationship to Primary Client:______________________ Program Entry Information Entry Date:____/______/______ (mm/dd/yyyy) Basic Demographics (Primary Client) Date of Birth: _____/_____/_____ Gender: Male: ______ Female:______ Race (Can check two if multi-racial): American Indian or Alaska Native_____ Asian_____ Black or African American_____ Native Hawaiian or Other Pacific Islander_____ Other_____ Other Multi-Racial_____ (SD)Middle Eastern Decent_____ White_____ Ethnicity: Hispanic/Latino: Yes ______ No _______ Is the Client a Natural Disaster Evacuee? Yes ______ No _______ Is Juvenile Parent: Yes ______ No _______ Is Client Homeless: Yes ______ No _______ Is Client Chronically Homeless: (Chronically homeless is defined as an unaccompanied individual with a disabling condition who has either been continuously homeless for a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years) Yes ______ No _______ Residential History Zip Code of Last Permanent Address (the five-digit zip code of the apartment, room, or house where the client last lived for 90 days or more): ________________ OR Dont Know____ Refused____ Prior Living Situation (the type of living arrangement the night before entry into the program): Domestic Violence Situation_____ Don't Know_____ Emergency Shelter_____ Foster Care/ Group Home_____ Hospital_____ Hotel/Motel w/o Emergency Shelter_____ Jail, Prison or Juvenile Facility_____ Living with Family_____ Living with Friends_____ Other_____ Own House/Apartment_____ Permanent Housing for Formerly Homeless_____ Place not meant for habitation_____ Psychiatric Hospital or Facility_____ Refused_____ Rental House/ Apartment_____ (SD)Childrens Shelter_____ (SD)College Dormitory_____ (SD)HOME Program_____ (SD)Licensed Group Home_____ (SD)Military Housing_____ (SD)Subsidized Housing_____ (SD)THP+_____ (SD)Transitional Living Program_____ Substance Abuse Treatment Center_____ Transitional Housing for the homeless_____ Length of Stay in Prior Living Situation: One week or less_____ More than one week, but less than one month_____ One to three months_____ More than 3 months, but less than one year_____ One year or longer_____ Explanation of Homelessness/Reason Homeless: Addiction_____ Criminal Activity_____ Divorce_____ Domestic Violence_____ Evicted_____ Family/Personal Illness_____ Health/Safety_____ Jail/Prison (Release from Institution)_____ Loss of Child Care_____ Loss of Public Assistance_____ Loss of Transportation_____ Medical Condition_____ Mental Health_____ Mortgage Foreclosure_____ Moved to seek work (Or new to Area_____ No Affordable Housing_____ Other_____ Personal Choice_____ Physical/Mental Disabilities_____ Substance Abuse_____ Substandard Housing_____ Unable to pay rent/mortgage_____ Underemployment/low income_____ Unemployment(Loss of Job)_____ Utility Shutoff_____ Since your last permanent address, what area of San Diego have you stayed in primarily? (Residential Comments) I.e. Clairemont, Mission Valley, Oceanbeach etc.. _________________________________ Income (Monthly Amounts) Entrance Income Sources and Amounts Source 1: Source 2: Source 3: Start Date: ________________________ Start Date: ________________________ Start Date: ________________________ Source*: ________________________ Source*: ________________________ Source*: ________________________ Amount: ________________________ Amount: ________________________ Amount: ________________________ *Income Sources: - A Veterans Disability Payment Alimony - Child Support - Earned Income - Food Stamps General Assistance - MEDICAID MEDICARE No financial Resources Other Other TANF Funded Resources Pension from a former job Private Disability Insurance Retirement Income from Social Security SCHIP - (SD)Annuities (SD)Chafee Grant (SD)Contributions from other people (SD)Dividends (investments) (SD)Financial Aid/Scholarship (SD)Interest (Bank) (SD)Pension/Retirement - (SD)Rental Income - (SD)State Disability - Section 8, Public Housing, or rental assistance - Self Employment Wages - Supplemental Nutrition Program for WIC SSDI - SSI - TANF TANF Child Care Services TANF Transportation Services Unemployment Insurance VA Medical Services Veterans Pension - Worker's Compensation Total Cash Family Monthly Income UPON ENTRY: _____________ Total Cash Family Monthly Income UPON EXIT: _____________ Medical Pregnant? Yes ______ No _______ If Yes, Projected Birth Date: _____/_____/_____ (mm/dd/yyyy) Disabilities: Disability #1: Disability #2: Disability #3: Start Date: ________________________ Start Date: ________________________ Start Date: ________________________ Type*: ________________________ Type*: ________________________ Type*: ________________________ Long Term: Yes____ No____ Long Term: Yes____ No____ Long Term: Yes____ No_____ *Disability Types: Alcohol Abuse - Developmental - Drug Abuse - HIV/AIDS - Mental Illness Other - Physical/ Medical - Physical/Mobility Limits - (SD)Alzheimer/Dementia (SD)Cognitive (SD)Hearing Impaired (SD)Learning - (SD)Mental Handicap/Injury (SD)Other (SD)Speech (SD)Vision Impaired Domestic Violence: Yes _____ No ______ Have you had a disability of a long duration (expected to be long-continued/indefinite duration)? Yes_____ No_____ Dont Know_____ Refused_____ Military Veteran: Yes ______ No _______ Program Exit Information Exit Date: ______/______/______ (mm/dd/yyyy) Reason for Leaving Program: (check only one) Completed Program_____ Criminal activity/violence_____ Death_____ Disagreement with rules/persons _____ Left for housing opp before completing program _____ Needs could not be met_____ Non-compliance with program_____ Non-Payment of rent_____ Other_____ Reached max time allowed_____ (SD)Another Program_____ (SD)Contract Ineligible_____ (SD)Court/Legal Removal_____ (SD)Failed Breathalyzer_____ (SD)Failed Urine Analysis_____ (SD)Joined Military_____ (SD)Left Program Prior to Completion_____ (SD)Medical Removal_____ (SD)Mental Health_____ (SD)Not Accepted Into Program_____ (SD)Physical Altercation_____ (SD)Possession of Drug/Alcohol/Paraphernalia_____ (SD)Possession of Tobacco Paraphernalia_____ (SD)Smoking Violation/Paraphernalia_____ (SD)Theft_____ Unknown/Disappeared_____ If Other, please specify: __________________________________________ Destination/Disposition: (check only one) Dont Know_____ Emergency Shelter _____ Foster Care/Group Home_____ Hospital (non-psychiatric)_____ Hotel/Motel without Emergency Shelter_____ Jail/Prison/Juvenile Detention Center_____ Other_____ Own House/Apartment_____ Permanent Housing for formerly Homeless (S+C, SHP, etc.)_____ Places not meant for habitation_____ Psychiatric hospital/facility_____ Refused_____ Rental Room/House/Apartment_____ (SD)Death_____ (SD)ILS-HOME program_____ (SD)ILS-THP +_____ (SD)ILS-Transitional Housing Program Young Adults_____ Staying in a family members room/apartment_____ Staying in a friends room/apartment_____ Substance abuse treatment/Detox center_____ Transitional Housing for Homeless_____ If Other Specify: __________________________________________ Tenure: Permanent_____ Transitional_____ Dont Know_____ Refused_____ Subsidy: None_____ Public Housing_____ Section 8_____ S + C_____ HOME Program_____ HOPWA Program_____ Other Housing Subsidy_____ Dont Know_____ Refused_____ Income Sources and Amounts Upon Exit **Please enter an end date, if an income source has ended since entry into the program.** Source 1: Source 2: Source 3: Start Date: ________________________ Start Date: ________________________ Start Date: ________________________ Source*: ________________________ Source*: ________________________ Source*: ________________________ Amount: ________________________ Amount: ________________________ Amount: ________________________ End Date: ________________________ End Date: ________________________ End Date: _______________________ Disabilities Upon Exit **Please enter an end date, if a disability has ended since entry into the program** Disability #1: Disability #2: Disability #3: Start Date: ________________________ Start Date: ________________________ Start Date: ________________________ Type*: ________________________ Type*: ________________________ Type*: ________________________ Long Term: Yes____ No____ Long Term: Yes____ No____ Long Term: Yes____ No_____ End Date: ________________________ End Date: ________________________ End Date: ________________________ Service Transactions Type Date Started/Given Notes **if you wish to further clarify service given Housing/Shelter (transitional, emergency, etc.) ______________ ____________________________________________ Food ______________ ____________________________________________ Material goods (clothing, personal hygiene, etc.) ______________ ____________________________________________ Legal Services ______________ ____________________________________________ Transportation ______________ ____________________________________________ Education ______________ ____________________________________________ Health Care ______________ ____________________________________________ Mental Health Care/Counseling ______________ ____________________________________________ Substance Abuse Services ______________ ____________________________________________ Employment ______________ ____________________________________________ Income Support (Social Insurance, Public Assistance) ______________ ____________________________________________ Case/care management ______________ ____________________________________________ Child Care ______________ ____________________________________________ Life Skills Education ______________ ____________________________________________ Other ______________ ____________________________________________ Other ______________ ____________________________________________ Other ______________ ____________________________________________ 0;<)DFNW}ʽʧ|gXLXLXL<hQ h 5CJOJQJ^Jh CJOJQJ^Jh 5CJOJQJ\^J(hmh 5B* CJOJQJ^Jph+hmh 5>*B* CJOJQJ^Jph(hJh 5B*CJOJQJ^Jph+hJh 56B*CJOJQJ^Jphhmh CJOJQJhG|h CJ!hr!h B* CJOJQJph3hmh B*CJ^Jphh B*CJ^Jph<n + ! 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