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CONTRA COSTA COUNCIL ON HOMELESSNESS

Contra Costa Homeless Management Information System

Contra Costa Standard HMIS Intake Form

*First Name _______________________ Middle ______ *Last Name* _____________________ *Suffix _____ (Jr/Sr.)

*Social Security No. ____________________________________________	Intake Date _______________________
Intake Counselor _____________________________________________	Agency /Program_________________________________________

Services Requested at Intake (check all that apply):

	Housing		Services/Other				Health
O	Emergency shelter	O	Basic needs: showers, mail, etc.	O	Employment/job training	O	Crisis intervention
O	Rental assistance	O	Benefits assistance	O	Food	O	Drug/alcohol treatment
O	Housing	O	Child care	O	Info and referral	O	Mental health
O	Section 8	O	Clothing	O	Legal services	O	Perinatal services
O	Security deposit	O	Counseling services	O	Transportation	O	Primary health care
		O	Domestic violence aid	O	Other

Note: All information requested below is voluntary, however some questions may be required by specific programs to determine eligibility.

1.Do you speak and understand English (Y/N)? ____ If no, what language are you most comfortable speaking?

O SpanishO Chinese O Vietnamese O Tagalog O ArabicO Other

2.	Who referred you to this program?
O	AB 109 probation officer		O	Residential program	O	HOPE Outreach
O	Friend		O	Skilled Nursing Facility	O	Central County Outreach
O	Family member		O	211 Crisis Line	O	Web/internet
O	Hospital (non-psychiatric)		O	Other Crisis Center	O	MSC/Drop-In center
O	Psychiatric hospital/facility		O	Shelter Hotline	O	Self
O	Criminal justice system (non AB 109)		O	Mental Health Access Line	O	Other______________________________________
O	Law enforcement/police		O	VA	O	Client doesn’t know
O	Shelter		O	Church/religious organization	O	Client refused to answer
O	Clinic/Outpatient facility		O	Benefits worker/case manager
3.	Nickname/Alias _________________________________				4. Maiden Name _______________________________

*5.	Birth Date: __________________ Check one: Full ______ Approximate/Partial _____ Client doesn’t know _____ Refused _______						Age: ____

*6.	Gender:	Check one: Male _____	Female _____ Transgender to Male _____ Transgender to female _____			Other _____ Client doesn’t know _____	Refused _____

7.If another adult is applying for services with you, please list their full name and relationship to you:

Relation to you:

Name: ________________________________________________________

O Spouse/Partner

O Child

O Nonrelative

O Other _________

*8.

Are you the Head of Household? _____

9. How many children in household? ____________

10. Total household size: ________

11.

Phone # (if any): _________________

12. Email (if any): ___________________________

13. Identification #: _________________

*14.

Ethnicity?

Hispanic/Latino

O Other (non-Hispanic/Latino)

Client Doesn’t Know

O Client Refused

*15.

What race BEST describes you? (check all that apply) [HUD recommendation: Those of Latin heritage should

mark American Indian if their ancestry from North, South or Central America. Those from the Far East (including India) should

mark Asian. Those from the Middle East should mark White.]

American Indian/Alaskan Native

Black/African-American

Client Doesn’t Know

Asian

White

Client Refused

O Native Hawaiian / Pacific Islander

*16.

Household Configuration:

O Single

O Couple Without Children

O Female Single Parent

Male Single Parent

Two Parent Family

O Other ___________

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 1 of 5

17. Sexual Orientation:

Heterosexual _____ Gay _____ Lesbian _____ Bisexual _____ Questioning/Unsure _____ Refused _______

*18. Have you ever served in the US Military:						Yes _____	No _____	Client doesn’t know _____	Client refused _____
If yes, Branch of the Military? Army ___					Navy ___	Air Force ___	Marines ___ Coast Guard ____
Year entered military service: __________							Year separated from military service: ________
Era (check all that apply):							Discharge Status:
O	World War II	O	Persian Gulf War	O	Iraq Dawn		O	Honorable	O	Bad Conduct
O	Korean War	O	Afghanistan	O	Other Peace-keeping		O	General under honorable	O	Dishonorable
O	Vietnam War	O	Iraq Freedom		Operations			conditions	O	Uncharacterized/Other
							O	Under other than honorable	O	Client doesn’t know
								conditions (OTH)	O	Client refused

Living Situation Info

*19. Please check what best describes your living situation last night (prior to entering this program):

OEmergency shelter, including hotel or motel paid for with emergency shelter voucher

OTransitional housing for homeless persons (including homeless youth)

OPermanent housing for formerly homeless persons (such as CoC project; HUD legacy programs; or

HOPWA PH)

OHotel or motel paid for without emergency shelter voucher

OPlace not meant for habitation (vehicle, abandoned bldg, train station/airport, or anywhere outside)

OSafe haven

OJail, prison, or juvenile detention facility

ORental by client, no ongoing housing subsidy

ORental by client, with VASH housing subsidy

ORental by client, with GPD TIP housing subsidy

ORental by client, with other ongoing housing subsidy

OOwned by client, no ongoing housing subsidy

OOwned by client, with ongoing housing subsidy

OStaying or living in a family member’s room,

apartment or house

OStaying or living in a friend’s room, apartment or house

OHospital or other residential non-psychiatric medical facility

OPsychiatric hospital or other psychiatric facility

OSubstance abuse treatment facility or detox center

OLong-term care facility or nursing home

OFoster care home or foster care group home

OResidential project or halfway house with no homeless criteria

OOther __________________________

OClient doesn’t know

OClient refused

*20. Length of living situation prior to entering this program:

O	One day or less	O	One to three months	O	Client doesn’t know
O	Two days to one week	O	More than three months, but less than one year	O	Client refused
O	More than one week, but less than one month	O	One year or longer

If less than 30 days or if coming from an institution, where were you living before?

O Emergency ShelterO Other (see item 19 for best description) _______________________________

*21. Housing Status at Program Entry

O	Category 1	– Homeless (i.e. streets, shelter, transitional housing)	O	Category 4 – Fleeing domestic violence	O	Client doesn’t know
O	Category 2	– At imminent risk of losing housing (within 14 days)	O	At-risk of homelessness	O	Client refused
O	Category 3	– Homeless only under other federal statutes	O	Stably housed

Note: Category 1 Homeless includes individuals recently exiting an institution who were homeless prior to entering the institution

22.Cause of homelessness? (Choose up to 3. Indicate 1 for primary reason, 2 for secondary reason. 3 for tertiary reason): For prevention programs, cause for potential homelessness?

O	Divorce/Separation ____	O	Domestic violence ____	O	Eviction ____
O	Loss of job ____	O	Low income ____	O	Mental illness ____
O	Parole ____	O	Ran away ____	O	Rent increase ____
O	Substance abuse ____	O	Thrown out ____	O	Other:________________________

*23. City where you lost stable housing (does not include shelter, transitional housing, or institutions). For prevention programs, city where you are at-risk of losing your housing?

O	Alamo	O	Byron	O	Danville	O	Kensington	O	Oakley	O	Port Costa
O	Antioch	O	Canyon	O	Diablo	O	Knightsen	O	Orinda	O	Richmond
O	Bay Point	O	Clayton	O	Discovery Bay	O	Lafayette	O	Pacheco	O	Rode
O	Bethel Island	O	Clyde	O	El Cerrito	O	Martinez	O	Pinole	O	San Pablo
O	Blackhawk	O	Concord	O	El Sobrante	O	Moraga	O	Pittsburg	O	San Ramon
O	Brentwood	O	Crockett	O	Hercules	O	N Richmond	O	Pleasant Hill	O	Walnut Creek
Other Bay Area County:
O	Alameda			O	Marin			O	Monterey
O	Napa			O	San Francisco			O	San Mateo
O	Santa Clara			O	Santa Cruz			O	Solano
O	Sonoma			O	Other County in CA __________________			O	Refused
Other City in the U.S.: _______________________					Other Country: ___________________________

*24. Last Permanent City and Zip Code (HUD definition: where client last resided for 90 days or more, not counting institutions, shelters, or transitional housing.) For prevention programs this may be where the client is currently residing.

City ____________________________ State _____ *Zip ___________ Client doesn’t know _____ Refused _____

25. What is your Current or Most Recent Mailing Address?

Address _________________________________________________

City ________________________ State _____ Zip ___________ Currently staying there (Y/N)?____

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 2 of 6

O Client refused

O Client doesn’t know

________ months

26.In which city did you sleep last night? (this means: where did you sleep prior to entering this program)

City ____________________________ State _____


*27.		Is this your first time experiencing homelessness (being without housing)? Yes _____		No _____ Client refused _____

		*28. Chronic Homelessness

	a.	Are you entering from the streets, shelter, or safe haven?	Yes _____ No _____ Client refused _____

		If yes, approximate date this episode of homelessness started (breaks of 7 days or less are acceptable)		: ____ / ____ / _____

*Note: To assist with this question, have the client look back to the date they last had a place to sleep that was not on the streets or in shelter. You may provide the client with HMIS data to help jog their memory. If the client knows the month and year but not the day, substitute the day of the month with the same day as project entry. Time spent in an institution or treatment facility may be counted if it was less than 90 days.

b.Regardless of where you stayed last night, number of times you have been homeless on the streets/shelter in the past three years including today.

O	Never in the past 3 years	O	3 times	O	Client doesn’t know
O	This is the first time	O	4 or more times	O	Refused

O2 times

c.Total Number of Months Homeless in the Past Three Years [Note: Any single day or part of a month spent

homeless should be counted as 1 month. Add up these episodes for a cumulative total.]:

29.Total length of time client has been homeless (without housing) [Short breaks are acceptable.]

____ years and ____months

*30. Is client’s length of homelessness documented, either in HMIS or in a paper file? Yes _____ No _____ Refused _____

Health and Disability Info

31. Are you (and your dependent children) capable of self-care?

O	Yes	O	Yes with assistance	O	No

*32.	Do you have a Disabling Condition?		Yes _____ No _____	Client doesn’t know _____	Client refused _____

This means: do you have a physical, mental, emotional, developmental disability, HIV/AIDS, diagnosable substance abuse problem, or chronic health condition of expected long duration that substantially limits your ability to live on your own?

*33. Please indicate Yes or No for each of the following disability types:

Yes/No

Severity

Long

Receiving

Yes/No

Severity

Long

Receiving

Yes/No Severity

Long

Receiving

Documented?

Term?

Aid?

Documented? Term?

Aid?

Documented? Term?

Aid?

Mental Health Problem _____

_____

HIV/AIDS

_____

7. Chronic Health

Alcohol Abuse

_____

Physical

_____

Condition

_____

Drug Abuse

_____

Developmental _____

_____

8. Other: _______

_____

Note: Chronic health condition – a diagnosed condition that is more than three months in duration and is either not curable or has residual effects that limit daily living and require

adaptation in function or special assistance. Examples include but are not limited to: heart disease, severe asthma, diabetes, arthritis-related conditions, adult onset cognitive impairments (including traumatic brain injury, post-traumatic distress syndrome, dementia, and other cognitive related conditions), severe headache/migraine, cancer, chronic bronchitis, liver condition, stroke, or emphysema.

PATH only: If answered Yes to Mental Health above, is it a Serious Mental Illness (SMI)? ____________

If answered Yes to Mental Health, Alcohol Abuse, or Drug Abuse above, indicate underneath each item how this was confirmed (CC = Confirmed thru clinical evaluation/assessment, CP = Confirmed by prior evaluation or clinic records, or U = Unconfirmed/Presumptive/Self Report).

34.

Have you ever been a victim of domestic violence? Yes _____

No _____ Client Doesn’t Know _____

Client Refused _____

If Yes, please indicate when the most recent domestic violence experience occurred:

Within the past 3 months

3-6 months ago

6-12 months ago

One year ago or more

Client doesn’t know

Client refused

Are you currently fleeing?

Yes _____

No _____

Client Doesn’t Know _____ Client Refused _____

*35. Are you currently covered by Health Insurance (Y/N)? _____

Client Doesn’t Know _____ Client Refused _____

Please answer Yes or No for each of the following Health Insurance Types:

Health Insurance

Currently

*HOPWA Only:

Health Insurance

Currently

*HOPWA Only:

covered (Y/N)?

If no, reason?

covered (Y/N)?

If no, reason?

Medicaid/Medi-Cal

Employer-provided Health Insurance

MEDICARE

Health insurance obtained through COBRA

State Children’s Health Insurance Program (SCHIP)

Private Pay Health Insurance

Veteran’s Administration (VA) Medical Services

State Health Insurance for Adults

*HOPWA Only: If not covered, indicate reason: (A= Applied but decision pending,

B = Applied but client was ineligible, C = Client did not apply, D =

Insurance Type not applicable.)

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 3 of 6

Income and Employment

36. Are you Employed (Y/N)? _____

If employed, type of employment? Full-time _____ Part-time _____	Seasonal _____
How many hours do you work each week? _____ Where? ________________________________
If unemployed, why? Looking for work _____ Unable to work _____	Not looking for work ______ Other ______________

*37. Any income received from any source in the last 30 days (Y/N)? _____ (answer Yes or No to each of the following):

Source

Any income

Amount

Source

Any income

Amount

received in

the past 30

days (Y/N)?

Earned Income (ie. employment income)

Child Support

Retirement Income from Social Security

Alimony or Other spousal support

Pension from a former job (including military retirement pay)

SSI

Private disability insurance

SSDI

Unemployment insurance

General Assistance

Workers Compensation

TANF

VA service-connected disability compensation

Other

VA non-service connected disability pension

No Financial Resources

*38. Current Total Monthly Income (for self and dependents under 18): $________________

*39. Any non-cash benefits received in the last 30 days (Y/N)? _____

(answer Yes or No to each of the following):

Source

Received in the past

Source

Received in the past 30

30 days (Y/N)?

days (Y/N)?

Supplemental Nutrition Assistance Program (Food Stamps)

WIC

TANF Child Care Services

Section 8, public housing, or other ongoing rental

assistance

TANF Transportation Services

Temporary rental assistance

Other TANF-funded services

Other: ________________________________

40. Are you eligible for public assistance you are not currently receiving?

Yes _____ No _____

Unsure _____

41. Have you lost any of the following public assistance in the last year?

SSI

SDI

Shelter Plus Care

Food Stamps

SSDI

Section 8

Subsidized Childcare

TANF/CalWORKS

Medi-Cal

Public Housing

Survivor’s Benefits

42. If so, why did you lose your public assistance?

O	Time Limit	O	Gained Employment	O	SSA error resulting in cutoff	O Sanctions/Non-Compliance
O	Eviction	O	Other ____________________

		Education
43.	Last grade completed?	O 9th Grade O 10th Grade O 11th Grade O 12th Grade O Some college
O	< 5th grade O Grade 5-6 O Grade 7-8
		O School program does not have grade
44.	Did you graduate from high school, get a GED, or certificate of high school proficiency (Y/N)? _____

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 4 of 6

Dependents

*45. Please list information about all dependent children (under 18 years old) in your household who will be participating in this program. (Add additional lines on back page if needed.)

First and Last Name

Relationship	Homeless	Birth Date
to HOH	Status (refer to
	page 2)

SS #	Gender
	(M/F)

Ethnicity

Race

Program Entry	Special
Date (if	Needs
different from
above)

46. Are there other family members that may be joining you in the future?

Name

Relationship to HOH

Age

Homeless Status (refer to page 2)

When will they be joining you?

Criminal History / Police Contact

47. Have you ever been convicted of a felony (Y/N)? ___	Explain: ________________________________________
Have you ever been convicted of a crime (Y/N)? ___	Explain: ________________________________________
Were you convicted within the last 6 months (Y/N)? ___

48.	Are you currently on probation (Y/N)? _____ Probation office’s name and phone no.: ______________________________________________
	Probation end date (mm/dd/yy): ___/___/___
49.	Are you currently on parole (Y/N)? _____ Parole office’s name and phone no.: ____________________________________________________
	Parole end date (mm/dd/yy): ___/___/___
50.	Have you ever been incarcerated in State/County/Federal Prison (Y/N)? _____
	If yes:
	a) Were you released as a result of California Assembly Bill (AB) 109 (Y/N)? _____
	b) Were you released within the last 6 months (Y/N)? ____

51.	Have you ever been held in city or county jail (Y/N)? _____	Explain: ______________________________________________________
	If yes: Were you held there within the last 6 months (Y/N)?	_____ How many times within last 6 months? ____

52. Where were you living prior to being held/incarcerated (jail/prison)?

O Emergency shelter, including hotel or motel paid for	O Jail, prison, or juvenile detention facility	O	Hospital or other residential non-psychiatric
with emergency shelter voucher	O Rental by client, no ongoing housing subsidy		medical facility
O Transitional housing for homeless persons (including	O Rental by client, with VASH housing subsidy	O Psychiatric hospital or other psychiatric facility
homeless youth)	O Rental by client, with GPD TIP housing subsidy	O Substance abuse treatment facility or detox
O Permanent housing for formerly homeless persons	O Rental by client, with other ongoing housing		center
(such as CoC project; HUD legacy programs; or	subsidy	O Long-term care facility or nursing home
HOPWA PH)	O Owned by client, no ongoing housing subsidy	O Foster care home or foster care group home
O Hotel or motel paid for without emergency shelter	O Owned by client, with ongoing housing subsidy	O Residential project or halfway house with no
voucher	O Staying or living in a family member’s room,		homeless criteria
O Place not meant for habitation (vehicle, abandoned	apartment or house	O	Other __________________________
bldg, train station/airport, or anywhere outside)	O Staying or living in a friend’s room, apartment or	O	Client doesn’t know
O Safe haven	house	O	Client refused

Client’s Emergency Contact ___________________________________ Phone No. _______________________

Signature of Applicant stating that all information is true & correct:________________________________

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 5 of 6

For SSVF/VASH Programs	For HOPWA Programs

1. Percentage of Area Median Income (AMI)

OLess than 30%

O30% to 50%

OGreater than 50%

* HUD sets new AMI income limits each year. Please refer to huduser.org for the most up-to-date AMI limits.

2. Homeless Prevention Screening Score: ____

*SSVF grantees must enter the 2-digit threshold score as was calculated in the homeless prevention screening/assessment.

3. VAMC Station Number: _______________

1. Receiving Public HIV/AIDS Medical Assistance? Yes / No
If no, reason?
O	Applied; decision pending	O Insurance type N/A for this client
O	Applied; client not eligible	O	Client doesn’t know
O	Client did not apply	O	Client refused
2. Receiving AIDS Drug Assistance Program (ADAP)? Yes / No
If no, reason?
O	Applied; decision pending	O Insurance type N/A for this client
O	Applied; client not eligible	O	Client doesn’t know
O	Client did not apply	O	Client refused

3. T-cell (CD4) Count Available?		Yes / No
If yes, T-Cell Count? (0-1500)		_______
How was the data obtained?
O	Medical Report
O	Client Report
O	Other

4. Viral Load Available?	Yes / No
If yes, Viral Load? (0-99999)	______
How was the data obtained?

OMedical Report

OClient Report

OOther

Signature of Applicant stating that all information is true & correct: _________________________________

* = HUD Required Fields

Questions in bold = Continuum Required

Modified 12/31/2015

Page 6 of 6

Question	Answer
Form Name	Hmis Intake Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	jail intake forms, hmis intake download, contra intake form, hmis intake pdf

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