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($$,=!$ ,=!=!r+T, 0+ /,, -0L-=,z 2=! 2,=!  d  ServicePoint 4.04 SAMPLE SINGLES Intake Form (rev 03/08) (Data elements in brown are optional for HUD programs but required for some San Diego City/County funded programs) **(SD) denotes answers that correspond to city/county reports and NOT the HUD APR** (PLEASE PRINT) Profile First Name:________________________ MI:_____ Last Name:___________________________________ Suffix:___________ SS #: _______-_____-_______ Program Entry Information Entry Date:____/______/______ Basic Demographics 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 _______ 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_____ Have you been chronically homeless? Yes______ No_______ (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) 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 Medical 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: ______/______/______ 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 ______________ ____________________________________________ Housing placement ______________ ____________________________________________ Material goods (clothing, personal hygiene, etc.) ______________ ____________________________________________ Legal Services ______________ ____________________________________________ Financial Aid ______________ ____________________________________________ Transportation ______________ ____________________________________________ Education ______________ ____________________________________________ Health Care ______________ ____________________________________________ HIV/AIDS related Services ______________ ____________________________________________ Mental Health Care/Counseling ______________ ____________________________________________ Substance Abuse Services ______________ ____________________________________________ Employment ______________ ____________________________________________ Income Support (Social Insurance, Public Assistance) ______________ ____________________________________________ Case/care management ______________ ____________________________________________ Child Care ______________ ____________________________________________ Life Skills Education ______________ ____________________________________________ Outreach ______________ ____________________________________________ Other ______________ ____________________________________________ Other ______________ ____________________________________________ Other ______________ ____________________________________________ 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