VI-SPDAT and Supplemental Questions for individuals ... · PDF fileOMB Number: 290090260 ....

Assessor: Greet the individual or otherwise establish relationship, being aware of creating a confidential, safe environment that establishes rapport and confidence. After signing of ROI(s) is complete, fill in pages 5-10.

Signed copies of the ROI, particularly VA ROI, should be uploaded to HMIS to allow case conferencing. Upload both HMIS and VA combined into same file. If separated, then VA ROI can be uploaded in the Files tab.

Opening Script

My name is ________, and I am a __________ (role) with the _____________ (program).

We will be complete a series of forms and questions today that will help us understand your situation and housing needs.

The first page we'll complete is called the Homeless Management Information System (HMIS) Client Information Sheet and Client Consent for Data Collection and Release of Information (ROI) and the VA ROI. These forms explain the purpose of data collection, the type of information collected, the risks and benefits of sharing information, and the safeguards we take to protect your information. By reading and signing the Client Consent, you're giving us permission to talk with other agencies and coordinate your entry into housing and services for you. We can then all work together to help you find housing.

The information is protected and stored in HMIS, a secure database that helps us connect people with housing, based on the needs and experiences you identify and the housing programs you are eligible for in King County. All the information you tell me is confidential and you should share as much as you feel comfortable.

After the Consent and Release of Information, I'll have a 10-15 minute survey I would like to complete with you. Most questions require only a YES or NO answer. Some questions require a one-word answer. I'll be honest, some questions are personal in nature. The more information you feel comfortable sharing, the smoother the referral process will be because we will know your options and won’t waste your time referring to you programs you aren’t eligible for. Keep in mind you can skip or refuse any question.

Do you have any questions before we begin?

VI-SPDAT and Supplemental Questions for individuals experiencing homelenessnessThis Packet contains: Opening Script and explanation of the process Page 2 - 4 Page 5 - 6 Page 7 - 8 Page 9 - 13 Page 14

HMIS and VA ROIPart 1 / Profile Questions: HUD Universal Data Elements for Client Creation Part 2 / Assessment Questions: Supplemental QuestionsPart 3 / VI-SPDATVI-SPDAT Scoring and close out questions, including Assessor Flag Notes

CEA Assessment Packet for Famillies, page 1 of 16 (Opening Script/Instructions)

King County Homeless Management Information System (HMIS)Client Consent for Data Collection and Release of Information

What is the HMIS? The HMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the HMIS for King County. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).

What is the purpose of this form? With this form, you can give permission to have information about you collected and shared with Partner Agencies that help King County provide housing and services. A current list of Partner Agencies is at http://kingcounty.hmis.cc/participating-agencies/

BY SIGNING THIS FORM, I AUTHORIZE King County and Bitfocus to share HMIS information with Partner Agencies. The HMIS information shared will be used to help me get housing and services. It will also be used to help evaluate the quality of housing and service programs. I understand that the Partner Agencies may change over time.

The information to be collected and shared includes: Name, birthday, gender, race, ethnicity, social security number, phone number, address Basic medical, mental health, substance use, and daily living information Housing Information Use of crisis services, hospitals and jail Employment, income, insurance and benefits information Services provided by Partner Agencies Results from assessments My photograph or other likeness (if included)

BY SIGNING THIS FORM, I UNDERSTAND THAT:

King County, Bitfocus and Partner Agencies will keep my HMIS information private using strictprivacy policies. I have the right to review their privacy policies.

There is a small risk of a security breach, and someone might obtain my information and use itinappropriately.

If I have questions about my privacy rights, my HMIS information, or am concerned that myinformation has been misused, I can contact my HMIS systems administrator at (206) 4444001 x2.

I can receive a copy of this Consent and the Client Information Sheet

I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.

This Consent will expire 7 years from my last HMIS recorded activity.

KING COUNTY HMIS CLIENT CONSENT TO DATA COLLECTION AND ROI (Version1.3 30Mar2016)

CEA Assessment Packet, page 7 of 7 (Page 7: KC Follow Up Questions)CEA Assessment Packet, page 7 of 7 (Page 7: KC Follow Up Questions)

CEA Assessment Packet for Families, page 2 of 16(HMIS ROI P1/2). Must be completed by ALL family household members age 18+

I may revoke this Consent earlier at any time in writing to:

Bitfocus, Inc. ATTN: King County HMIS 548 Market St #60866 San Francisco, CA 941045401

The revocation will take effect upon receipt, except to the extent others have already acted under thisConsent.

My HMIS information may be viewed by auditors or funders who review work of the PartnerAgencies, including HUD, The Department of Veteran Affairs, The Department of Health and HumanServices, and The Washington State Department of Commerce. I understand that the list of auditorsand funders may change over time.

My HMIS information may be shared to coordinate referral and placement for housing and services.

My HMIS information may be further shared by the Partner Agencies to other agencies for carecoordination, counseling, food, utility assistance, and other services.

My HMIS information will be combined with other information from the Washington State Departmentof Social and Health Services (DSHS) to help evaluate the quality of social services.

My HMIS information may be used for research; however, my identity will remain private.

Important: Personal information is not entered in HMIS for people who are 1) receiving services from domestic violence agencies; 2) fleeing or in danger from domestic violence, dating violence, sexual assault or stalking situation; or 3) have revealed information about being HIV positive or having AIDS. If one of these situations applies to you, DO NOT agree to have your personal identifying information collected.

SIGNATURE:

______________________________________ Signature of Patient/Client or Representative:

______________________________________ PRINTED NAME

_________________ Date

KING COUNTY HMIS CLIENT CONSENT TO DATA COLLECTION AND ROI (Version1.3 30Mar2016)

CEA Assessment Packet for Families, page 3 of 16 (HMIS ROI P2/2). Must be completed by ALL family household members age 18+

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OMB Number: 290090260 Estimated burden: 2 Minutes Expiration Date: 10/31/3003

REQUEST FOR AND AUTHORIZATION TO RELEASE OF MEDICAL RECORDS OR HEALTH INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We expect that the time expended by all individuals completing this form will average 2 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to specifically outline the circumstances under which we may disclose data

The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a and 38 U.S.C 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will not be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED.

TO: Department of Veterans Affairs (Print or type name

and address of Health care facility)

VA Puget Sound Health Care System 1660 S. Columbian Way, Seattle, WA 98108

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

NAME AN

PATIE

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED.

CLIENT WILL INITIAL ALL OF THE BELOW APPLICABLE TO THIS AUTHORIZATION TO RELEASE.____Bellwether Housing ____Bread of Life Mission ____BitFocus Homeless Management Information System ____Capitol Hill Housing ____Catholic Community Services ____Catholic Housing Services ____Chief Seattle Club ____Community Psychiatric Clinic ___Compass Housing Alliance____Congregations for the Homeless ____DESC _____El Centro de la Raza ____Evergreen Treatment Services/REACH ____Harborview Medical Center ____Housing Authorities: King, Seattle, Renton ____Hopelink ____Imagine Housing ____ITFH ____King County Department of Community & Human Services ____LIHI ____Multi Service Center ____NAVOS ____Operation Nightwatch ____Pioneer Human Services ____Plymouth Housing Group ____Salvation Army ____Seattle Indian Health Center ____Seattle-King County Public Health ____Seattle Human Services/Office of Housing ____SHARE/WHEEL ____Sound Mental Health ____Solid Ground ____St. Vincent de Paul ____Therapeutic Health Services ____Union Gospel Mission ____United Way King County

____Valley Cities Counseling & Consultation ____Vietnam Veterans Leadership Program ____Washington State Department of Veterans Affairs ____YWCA

____Other: ____________________________________________________________________________

____SELECT ALL LISTED AGENCIES

VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to the

organization, or individual named on this request. I understand the information to be released include information regarding the following

condition(s):

DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE HUMAN IMMUNODEFICIENCY VIRUS (HIV) SICKLE CELL ANEMIA

INFORMATION REQUESTED: (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each)

COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT NOTE(S) OTHER (Specify) VA medical,

Answers from VI-SPDAT/VI-Family-SPDAT survey, demographic information, veteran status, income amount and source, legal information, use of case management, and VA healthcare eligibility.PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

For intake purposes, housing placement and referral, case management, coordination.

NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information

given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on year of signature (date supplied by patient: or (3) under the following condition(s): Discharge from the VA Community Housing and Outreach Services programs. NOTE: The authorization signed on this release will not exceed one year from the date signed.

Date: Signature of Patient or Person Authorized to Sign for Patient

FOR VA USE ONLY

IMPRINT Patient Data Card (Name, Address, Social Security

Number) Type and Extent of Material Released

Date Released Released By:

VA FORM 10-5345 MAR 2003

THIS SUPERSEDES VA FORM 10-5345, DATED JUN.2001, WHICH WILL NOT BE USED

Department of Veterans Affairs

CEA Assessment Packet for Families, page 4 of 16 (VA ROI ) Must be completed by all veteran family members

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!ǎǎŜǎǎƻǊ C bŀƳŜ

!ǎǎŜǎǎƻǊ !ƎŜƴŎȅ

!ǎǎŜǎǎƻǊ [ bŀƳŜ

ǳǊǾŜȅ [ƻŎŀǘƛƻƴ

Part 1) UNIVERSAL DATA ELEMENTS FOR CLIENT CREATION ASSESSMENT DATE format: m / d / yyyy

SOCIAL SECURITY NUMBER format # # # - # # - # # # # QUALITY OF SOCIAL SECURITY

Cǳƭƭ b ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ !ǇǇǊƻȄƛƳŀǘŜ ƻǊ ǇŀǊǘƛŀƭ b ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

CURRENT NAME LAST

CƛǊǎǘ

aƛŘŘƭŜ bƻ aƛŘŘƭŜ ǳŦŦƛȄ bƻ ǳŦŦƛȄ

bƛŎƪƴŀƳŜ bƻ bƛŎƪƴŀƳŜ QUALITY OF NAME

Cǳƭƭ bŀƳŜ ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ tŀǊǘƛŀƭΣ ǎǘǊŜŜǘ ƴŀƳŜΣ ƻǊ ŎƻŘŜ ƴŀƳŜ ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

format m / d / y y y y DATE OF BIRTH

QUALITY OF DATE OF BIRTH

!ƎŜ όІύ

Cǳƭƭ 5h. ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ !ǇǇǊƻȄƛƳŀǘŜ ƻǊ ǇŀǊǘƛŀƭ 5h. ǊŜǇƻǊǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

GENDER CŜƳŀƭŜ ¢ǊŀƴǎƎŜƴŘŜǊ ƳŀƭŜ ǘƻ ŦŜƳŀƭŜ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ aŀƭŜ ¢ǊŀƴǎƎŜƴŘŜǊ ŦŜƳŀƭŜ ǘƻ ƳŀƭŜ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ hǘƘŜǊ ǇŜŎƛŦȅ άhǘƘŜǊέΥ

²ƘƛǘŜκ/ŀǳŎŀǎƛŀƴ !ƳŜǊƛŎŀƴ LƴŘƛŀƴ ƻǊ !ƭŀǎƪŀƴ bŀǘƛǾŜ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ .ƭŀŎƪκ!ŦǊƛŎŀƴ !ƳŜǊƛŎŀƴ Iŀǿŀƛƛŀƴ ƻǊ hǘƘŜǊ tŀŎƛŦƛŎ LǎƭŀƴŘŜǊ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ !ǎƛŀƴ

ETHNICITY bƻƴ IƛǎǇŀƴƛŎκbƻƴ [ŀǘƛƴƻ IƛǎǇŀƴƛŎ κ [ŀǘƛƴƻ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ

VETERAN STATUS / Did you serve in the US Military? bƻ ¸Ŝǎ

LŦ YES ǘƻ ±ŜǘŜǊŀƴ ǘŀǘǳǎ κ aƛƭƛǘŀǊȅ ŜǊǾƛŎŜ ǘƘŜƴΥ Year entered ƳƛƭƛǘŀǊȅ ǎŜǊǾƛŎŜ όȅŜŀǊύ Year Separated ƳƛƭƛǘŀǊȅ ǎŜǊǾƛŎŜ όȅŜŀǊύ

/ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ World War II bƻ ¸Ŝǎ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Korean War bƻ ¸Ŝǎ

Vet era of service continues Next Page





If a Vet, it is critical to complete and upload the VA ROI for VA to be able to coordinate services with housing partners

CEA Assessment for Families, page 5 of 16 (Profile Q's / HUD Universal data P1/2). All Questions this page must be completed for ALL FAMILY MEMBERS

RACE

Vet era of service (continued)

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Vietnam War bƻ ¸Ŝǎ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Persian Gulf War (Desert Storm) bƻ ¸Ŝǎ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Afghanistan (Operation Enduring Freedom) bƻ ¸Ŝǎ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Iraq (Operation bƻ ¸Ŝǎ

¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Iraq (Operation New Dawn) bƻ ¸Ŝǎ

/ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ





¢ƘŜŀǘŜǊ ƻŦ hǇŜǊŀǘƛƻƴǎΥ Other peace-keeping operations ƻǊ ƳƛƭƛǘŀǊȅ ƛƴǘŜǊǾŜƴǘƛƻƴǎ όǎǳŎƘ ŀǎ [ŜōŀƴƻƴΣ tŀƴŀƳŀΣ ƻƳŀƭƛŀΣ .ƻǎƴƛŀΣ Yƻǎƻ

bƻ ¸Ŝǎ

BRANCH OF THE MILITARY όƛŦ ƳǳƭǘƛǇƭŜ ōǊŀƴŎƘŜǎΣ Ƴƻǎǘ ǊŜŎŜƴǘύ !ǊƳȅ !ƛǊ CƻǊŎŜ bŀǾȅ aŀǊƛƴŜǎ /ƻŀǎǘ DǳŀǊŘ

DISCHARGE STATUS όƛŦ ƳǳƭǘƛǇƭŜ ŘƛǎŎƘŀǊƎŜǎΣ Ƴƻǎǘ ǊŜŎŜƴǘύ IƻƴƻǊŀōƭŜ .ŀŘ /ƻƴŘǳŎǘ



/ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ DŜƴŜǊŀƭ ǳƴŘŜǊ IƻƴƻǊŀōƭŜ hǘƘŜǊ ǘƘŀƴ IƻƴƻǊŀōƭŜ όh¢Iύ

5ƛǎƘƻƴƻǊŀōƭŜ

¦ƴŎƘŀǊŀŎǘŜǊƛȊŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

Part 2) SUPPLEMENTAL QUESTIONS hY ǘƻ tǊŜŦŜǊǊŜŘ ƭŜŀǾŜ ŎƻƴǘŀŎǘ

CLIENT CONTACT INFORMATION

tƘƻƴŜΥ

!ƭǘ tƘƻƴŜΥ

¢ŜȄǘΥ

ŜƳŀƛƭΥ

ƳŜǎǎŀƎŜ ƳŜǘƘƻŘΚ

ό¸ύ ό·ύ

hǘƘŜǊ όŜƎΣ ŦŀŎŜōƻƻƪύΥ όǎƻŎƛŀƭ ƳŜŘƛŀΣ ŜǘŎΦύΣ [ŀǎǘ tŜǊƳŀƴŜƴǘ ½ƛǇΥ

/ƻƴǘŀŎǘΥ

ON A REGULAR DAY, WHAT TIME AND PLACE IS EASIEST TO FIND YOU?

Write in

The following Contact Info can ALSO be entered in the Locations Tab

AddressΥ

City:

StateΥ

ZipΥ

CEA Assessment Packet for Families, page 6 of 16 (Profile Q's 2/2 + Contact Info)

TOTAL MONTHLY INCOME AND PERCENT AMI per MO όǿǊƛǘŜ ƛƴ ¢ƻǘŀƭ ƳƻƴǘƘƭȅ LƴŎƻƳŜ ŦǊƻƳ ŀƭƭ ǎƻǳǊŎŜǎύ¦ƴŘŜǊ ол҈ !aL ол҈ ǘƻ рл҈ !aL

DǊŜŀǘŜǊ ǘƘŀƴ рл҈

1 2 3 4 5 6 7


AMI: 30% μμ мΣруо μ мΣулу μ нΣлоо μ нΣнру μ нΣппн μ нΣтмр μ оΣлсм AMI: 50% μμ нΣсоу μ оΣлмо μ оΣоуу μ оΣтсо μ пΣлст μ пΣост μ пΣсст

DO YOU HAVE SUPPLEMENTAL SECURITY INCOME (SSI) OR SOCIAL SECURITY DISABILITY INSURANCE (SSDI)? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ WHAT TYPE OF HEALTH INSURANCE DO YOU HAVE, IF ANY?

aŜŘƛŎŀƛŘ tǊƛǾŀǘŜ LƴǎǳǊŀƴŎŜ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ aŜŘƛŎŀǊŜ bƻ IŜŀƭǘƘ LƴǎǳǊŀƴŎŜ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ ±! aŜŘƛŎŀƭ hǘƘŜǊ

HAVE YOU EVER BEEN IN FOSTER CARE? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ


DO YOU HAVE 51% (OR GREATER) CUSTODY OF AT LEAST ONE CHILD? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ


WHERE DID YOU LIVE PRIOR TO BECOMING HOMELESSΚ ¢Ƙƛǎ /ƛǘȅ !ƴƻǘƘŜǊ ǇŀǊǘ ƻŦ ²! ǘŀǘŜ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ YƛƴƎ /ƻǳƴǘȅ ό¢Ƙƛǎ wŜƎƛƻƴύ ƻƳŜǿƘŜǊŜ 9ƭǎŜ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

DO YOU OR SOMEONE IN YOUR FAMILY HAVE A MEDICAL condition wƘƛŎƘ ǊŜǉǳƛǊŜǎ ǘǊŜŀǘƳŜƴǘ ƻǊ ƳŜŘƛŎŀǘƛƻƴ ȅƻǳ Ŏŀƴϥǘ Ƴŀƛƴǘŀƛƴ ōŜŎŀǳǎŜ ƻŦ ƘƻƳŜƭŜǎǎƴŜǎǎ

bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

Acute medical Needs Notes

WHAT IS YOUR CURRENT LIVING SITUATION? (CHOOSE ONLY ONE, make note of letter for additional Q's following page) !π5Υ [ƛǘŜǊŀƭƭȅ IƻƳŜƭŜǎǎ Yπ±Υ ¢Ǌŀƴǎƛǘƛƻƴŀƭ ƻǊ tŜǊƳŀƴŜƴǘ IƻǳǎƛƴƎ

ŀΥ ǇƭŀŎŜ ƴƻǘ ƳŜŀƴǘ ŦƻǊ Ƙŀōƛǘŀǘƛƻƴ όŎŀǊΣ ǘŜƴǘΣ ƻǳǘǎƛŘŜΣ ŀōŀƴŘƻƴ ōƭŘƎύōΥ ŜƳŜǊƎŜƴŎȅ ǎƘŜƭǘŜǊ όƛƴŎƭǳŘƛƴƎ ƘƻǘŜƭ ǇŀƛŘ ǿκ±ƻǳŎƘŜǊύ ŎΥ ŀŦŜ IŀǾŜƴ ŘΥ LƴǘŜǊƛƳ IƻǳǎƛƴƎ

ŦΥ ƘƻǎǇƛǘŀƭ κ ǊŜǎƛŘŜƴǘƛŀƭ ƴƻƴπǇǎȅŎƘƛŀǘǊƛŎ ƳŜŘƛŎŀƭ ŦŀŎƛƭƛǘȅ ƎΥ ƧŀƛƭΣ ǇǊƛǎƻƴ ƻǊ ƧǳǾŜƴƛƭŜ ŘŜǘŜƴǘƛƻƴ ŦŀŎƛƭƛǘȅ ƘΥ ƭƻƴƎπǘŜǊƳ ŎŀǊŜ ŦŀŎƛƭƛǘȅ ƻǊ ƴǳǊǎƛƴƎ ƘƻƳŜ ƛΥ ǇǎȅŎƘƛŀǘǊƛŎ ƘƻǎǇƛǘŀƭ ƻǊ ŦŀŎƛƭƛǘȅ ƧΥ ǎǳōǎǘŀƴŎŜ ŀōǳǎŜ ŦŀŎƛƭƛǘȅ ƻǊ ŘŜǘƻȄ ŎŜƴǘŜǊ

²π¸Υ ¦ƴƪƴƻǿƴ ǿΥ ŎƭƛŜƴǘ ŘƻŜǎƴϥǘ ƪƴƻǿ ȄΥ ŎƭƛŜƴǘ ǊŜŦǳǎŜŘ ȅΥ Řŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

ƪΥ ƘƻǘŜƭκƳƻǘŜƭ ǇŀƛŘ ŦƻǊ ǿƛǘƘƻǳǘ 9 ǾƻǳŎƘŜǊ όǎŜƭŦπǇŀƛŘύ ƭΥ ƻǿƴŜŘ ōȅ ŎƭƛŜƴǘΣ ƴƻ ƻƴƎƻƛƴƎ ǎǳōǎƛŘȅ ƳΥ ƻǿƴŜŘ ōȅ ŎƭƛŜƴǘΣ ǿƛǘƘ ƻƴƎƻƛƴƎ ǎǳōǎƛŘȅ ƴΥ ǇŜǊƳŀƴŜƴǘ ƘƻǳǎƛƴƎ ŦƻǊ ŦƻǊƳŜǊƭȅ ƘƻƳŜƭŜǎǎ όŜƎΣ tIΣ Iht²!ύ ƻΥ ǊŜƴǘŀƭ ōȅ ŎƭƛŜƴǘΣ ƴƻ ƻƴƎƻƛƴƎ ǎǳōǎƛŘȅ ǇΥ ǊŜƴǘŀƭ ōȅ ŎƭƛŜƴǘΣ ǿƛǘƘ ±!I ǎǳōǎƛŘȅ ǉΥ ǊŜƴǘŀƭ ōȅ ŎƭƛŜƴǘΣ ǿƛǘƘ Dt5 ¢Lt ǎǳōǎƛŘȅ ǊΥ ǊŜƴǘŀƭ ōȅ ŎƭƛŜƴǘΣ ǿƛǘƘ h¢I9w ƻƴƎƻƛƴƎ ǎǳōǎƛŘȅ ǎΥ ǊŜǎƛŘŜƴǘƛŀƭ ǇǊƻƧŜŎǘ κ ƘŀƭŦǿŀȅ ƘƻǳǎŜΣ ƴƻ ƘƻƳŜƭŜǎǎ ŎǊƛǘŜǊƛŀ ǘΥ ǎǘŀȅƛƴƎκƭƛǾƛƴƎ ƛƴ ŀ C!aL[¸ ƳŜƳōŜǊǎ ǊƻƻƳΣ ŀǇǘ ƻǊ ƘƻǳǎŜ ǳΥ ǎǘŀȅƛƴƎκƭƛǾƛƴƎ ƛƴ ŀ CwL9b5ϥ ǊƻƻƳΣ ŀǇǘ ƻǊ ƘƻǳǎŜ ǾΥ ǘǊŀƴǎƛǘƛƻƴŀƭ ƘƻǳǎƛƴƎ ŦƻǊ ƘƻƳŜƭŜǎǎ ǇŜǊǎƻƴǎ

9πWΥ Lƴǎǘƛǘǳǘƛƻƴ ŜΥ ŦƻǎǘŜǊ ŎŀǊŜ ƘƻƳŜκƎǊƻǳǇ ƘƻƳŜ

CEA Assessment Packet for Families, page 7 of 16 ( Supplemental Q's 1/4)

DOES AT LEASE ONE ADULT IN THE HOUSEHOLD HAVE A DISABILITY? bƻ ¸Ŝǎ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ


For All Living Situations A - Y: How long have you been in your current situation? hƴŜ ƴƛƎƘǘ ƻǊ ƭŜǎǎ hƴŜ ƳƻƴǘƘ ƻǊ ƳƻǊŜΣ ōǳǘ ƭŜǎǎ ǘƘŀƴ фл Řŀȅǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ ¢ǿƻ ǘƻ ǎƛȄ ƴƛƎƘǘǎ фл Řŀȅǎ ƻǊ ƳƻǊŜΣ ōǳǘ ƭŜǎǎ ǘƘŀƴ ƻƴŜ ȅŜŀǊ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ hƴŜ ǿŜŜƪ ƻǊ ƳƻǊŜΣ ōǳǘ ƭŜǎǎ ǘƘŀƴ ƻƴŜ ƳƻƴǘƘ hƴŜ ȅŜŀǊ ƻǊ ƭƻƴƎŜǊ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

A - D: [ Literally Homeless ] then: APPROXIMATELY WHEN DID THIS HOMELESS SITUATION BEGIN?

Lƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎ ǿƘŀǘ ƛǎ ǘƘŜ ǘƻǘŀƭ ƴǳƳōŜǊ ƻŦ TIMES ȅƻǳ ƘŀǾŜ ōŜŜƴ ƘƻƳŜƭŜǎǎ ƻƴ ǘƘŜ ǎǘǊŜŜǘǎΣ 9 ƻǊ ǎŀŦŜ ƘŀǾŜƴΚ

hƴŜ ǘƛƳŜ ¢ƘǊŜŜ ǘƛƳŜǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ ¢ǿƻ ǘƛƳŜǎ CƻǳǊ ƻǊ ƳƻǊŜ ǘƛƳŜǎ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

Lƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎ ǿƘŀǘ ƛǎ ǘƘŜ ǘƻǘŀƭ ƴǳƳōŜǊ ƻŦ MONTHS ȅƻǳ ƘŀǾŜ ōŜŜƴ ƘƻƳŜƭŜǎǎ ƻƴ ǘƘŜ ǎǘǊŜŜǘǎΣ 9 ƻǊ ǎŀŦŜ ƘŀǾŜƴΚ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ /ƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

E - J: [ Institution ] then: Did you stay LESS THAN 90 DAYS?

bƻ Yes /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

If stay Y: LESS than 90: ƻƴ ǘƘŜ ƴƛƎƘǘ ōŜŦƻǊŜ ς ǎǘŀȅŜŘ ƻƴ ǎǘǊŜŜǘǎΣ 9Σ ƻǊ ŀŦŜ IŀǾŜƴ bƻ Yes If Y: Streets/ES/SH: !ǇǇǊƻȄƛƳŀǘŜƭȅ ǿƘŜƴ ŘƛŘ ǘƘƛǎ ƘƻƳŜƭŜǎǎ ǎƛǘǳŀǘƛƻƴ ōŜƎƛƴ

LŦ Y: Streets/ES/SH bǳƳōŜǊ ƻŦ TIMES ƻƴ ǘƘŜ ǎǘǊŜŜǘǎΣ ƛƴ 9Σ ƻǊ ŀŦŜ IŀǾŜƴ ƛƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎΚ hƴŜ ǘƛƳŜ ¢ƘǊŜŜ ǘƛƳŜǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ ¢ǿƻ ǘƛƳŜǎ CƻǳǊ ƻǊ ƳƻǊŜ ǘƛƳŜǎ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

LŦ Y: Streets/ES/SHΥ ǘƻǘŀƭ ƴǳƳōŜǊ ƻŦ MONTHS ƘƻƳŜƭŜǎǎ ƻƴ ǘƘŜ ǎǘǊŜŜǘǎΣ 9 ƻǊ ŀŦŜ IŀǾŜƴ ƛƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ collected /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

K - V: [ Transitional or Permanent Housing or Unknown/Not Collected ] then: Did you stay LESS THAN 7 NIGHTS?

bƻ Yes /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

If Y: stay LESS than 7 nights, how long did you stay: /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ hƴŜ ƴƛƎƘǘ ƻǊ ƭŜǎǎ ¢ǿƻ ǘƻ ǎƛȄ ƴƛƎƘǘǎ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

If Y: stay LESS than 7 nights: ƻƴ ǘƘŜ ƴƛƎƘǘ ōŜŦƻǊŜ π ǎǘŀȅŜŘ ƻƴ ǎǘǊŜŜǘǎΣ 9 ƻǊ ŀŦŜ IŀǾŜƴ bƻ Yes

If Y: Streets/ES/SH: !ǇǇǊƻȄƛƳŀǘŜƭȅ ŘŀǘŜ ƘƻƳŜƭŜǎǎƴŜǎǎ ǎǘŀǊǘŜŘ

If Y: Streets/ES/SHΥ ǘƻǘŀƭ ƴǳƳōŜǊ ƻŦ TIMES ƘƻƳŜƭŜǎǎ ƻƴ ǘƘŜ ǎǘǊŜŜǘǎΣ 9 ƻǊ ŀǾŜ IŀǾŜƴ ƛƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎΚ hƴŜ ǘƛƳŜ ¢ƘǊŜŜ ǘƛƳŜǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ ¢ǿƻ ǘƛƳŜǎ CƻǳǊ ƻǊ ƳƻǊŜ ǘƛƳŜǎ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

If Y: Streets/ES/SHΥ ǘƻǘŀƭ ƴǳƳōŜǊ ƻŦ MONTHS ƘƻƳŜƭŜǎǎ ƻƴ ǎǘǊŜŜǘǎΣ 9 ƻǊ I ƛƴ ǘƘŜ Ǉŀǎǘ ǘƘǊŜŜ ȅŜŀǊǎΚ

5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ


DISABLING CONDITION AND BARRIERS DO YOU HAVE A DISABLING CONDITION


DO YOU HAVE A PHYSICAL DISABILITY? /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

IF you have a physical disability, are you currently receiving services? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ IF you have a physical disability, is it a long term physical disability?


IF you have a physical disability, is it documented? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ


DO YOU OR ANYONE IN YOUR FAMILY HAVE A PERMANENT PHYSICAL DISABILITY THAT LIMITS YOUR MOBILITY? (i.e., wheelchair, amputation, unable to climb stairs?)


DO YOU HAVE A DEVELOPMENTAL DISABILITY? /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

IF you have a developmental disability, are you currently receiving services? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

IF you have a developmental disability, does it substantially impair your independence?


IF you have a developmental disability, is it documented? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ


DO YOU HAVE A CHRONIC HEALTH CONDITION? /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

IF you have a chronic health condition, are you currently receiving services? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ IF you have a chronic health condition, is it a long-term chronic health condition?


IF you have a chronic health condition, is it documented? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ



bƻ ¸Ŝǎ

bƻ ¸Ŝǎ

bƻ ¸Ŝǎ

bƻ ¸Ŝǎ


DO YOU HAVE A MENTAL HEALTH PROBLEM? /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

IF you have a mental health problem, are you currently receiving services? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ IF you have a mental health problem, is it a long-term mental health problem?


IF you have a mental health problem, is it documented? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ


DO YOU HAVE A SUBSTANCE ABUSE PROBLEM? bƻ ¸ŜǎΣ ŘǊǳƎ ŀōǳǎŜ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ ¸ŜǎΣ ŀƭŎƻƘƻƭ ŀōǳǎŜ ¸ŜǎΣ ōƻǘƘ ŀƭŎƻƘƻƭ ŀƴŘ ŘǊǳƎ ŀōǳǎŜ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

IF you have a substance abuse problem, are you currently receiving services? bƻ ¸Ŝǎ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ

/ƭƛŜƴǘ ǊŜŦǳǎŜŘ IF you have a substance abuse problem, is it a long-term substance abuse problem?


IF you have a substance abuse problem, is it documented?


DO YOU HAVE A CRIMINAL BACKGROUND IN ANY OF THE FOLLOWING? wŜƎƛǎǘŜǊŜŘ ǎŜȄ ƻŦŦŜƴŘŜǊ !Ǌǎƻƴ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ aŜǘƘ tǊƻŘǳŎǘƛƻƴ hǇŜƴ ²ŀǊǊŀƴǘ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ /ƭŀǎǎ ! CŜƭƻƴȅ ǿκƛƴ мн ƳƻƴǘƘǎ

ARE YOU INTERESTED IN BEING REFERRED TO PROGRAMS THAT SPECIALIZE IN SERVING THOSE WHO LŘŜƴǘƛŦȅ ŀǎ !ǎƛŀƴ IŀǾŜ ŀ ǘǊƛōŀƭ ŘŜǎƛƎƴŀǘƛƻƴ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ 5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ LŘŜƴǘƛŦȅ ŀǎ .ƭŀŎƪκ!ŦǊƛŎŀƴ !ƳŜǊƛŎŀƴ LŘŜƴǘƛŦȅ ŀǎ [D.¢v /ƭƛŜƴǘ ǊŜŦǳǎŜŘ LŘŜƴǘƛŦȅ ŀǎ IƛǎǇŀƴƛŎκ[ŀǘƛƴƻ !ǊŜ ƛƴ wŜŎƻǾŜǊȅ LŘŜƴǘƛŦȅ ŀǎ ƛƳƳƛƎǊŀƴǘ ƻǊ ǊŜŦǳƎŜŜ !ǊŜ 9ȄπhŦŦŜƴŘŜǊκwŜπ9ƴǘǊȅ

!ǊŜ 5ŜŀŦ κ IŜŀǊƛƴƎ LƳǇŀƛǊŜŘ

Client Data

Client Not IF YES’ TO VETERAN STATUS, MILITARY SERVICES, ARE YOU: No Yes doesn't know refused collected

Ҕ wŜƎƛǎǘŜǊŜŘ ǿƛǘƘ ǘƘŜ ±! tǳƎŜǘ ƻǳƴŘ IŜŀƭǘƘŎŀǊŜ ȅǎǘŜƳΚ

Ҕ 9ƭƛƎƛōƭŜ ŦƻǊ ±! IŜŀƭǘƘŎŀǊŜΚ

Ҕ IŀŘ ŀǘ ƭŜŀǎǘ ƻƴŜ Řŀȅ ƻŦ !ŎǘƛǾŜ 5ǳǘȅΚ


bƻ ¸Ŝǎ

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SOME PROGRAMS REQUIRE PROOF OF A VALID SOCIAL SECURITY NUMBER AND LEGAL IMMIGRANTS STATUS. Are you interested in being referred to one of these programs?

5ŀǘŀ ƴƻǘ ŎƻƭƭŜŎǘŜŘ /ƭƛŜƴǘ ŘƻŜǎƴΩǘ ƪƴƻǿ /ƭƛŜƴǘ ǊŜŦǳǎŜŘ

bƻ ¸Ŝǎ

FAMILIES Vulnerability Index - Service Prioritization Decision Assistance Tool (VI-SPDAT) American Version 2.0

NicknameParent 1: First Name Last Name

In what language do you feel best able to express yourself?

IF 9L¢I9w I9!5 hC Ih¦9Ih[5 IS 60 YEARS OF AGE OR OLDER, THEN SCORE 1. AGE SCORE:

Parent 2: First Name Nickname Last Name

Date of BirthParent 1 Age P1

No second parent currently part of household. If there is, complete that parent info below:

Children

1. How many children under the age of 18 are currently with you?

2. How many children under the age of 18 are not currently with your family, butbut you have reason to believe they will be joining you when you get housed?

3. IF HOUSEHOLD INCLUDES A FEMALE: Is any member of thefamily currently pregnant?

4. Please provide a list of children’s names and ages:

First Name Last Name AgeDate of Birth

IF THERE IS A SINGLE PARENT WITH 2+ CHILDREN, AND/OR A CHILD AGED 11 OR YOUNGER, AND/OR A CURRENT PREGNANCY, THEN SCORE 1 FOR FAMILY SIZE.

IF THERE ARE TWO PARENTS WITH 3+ CHILDREN, AND/OR A CHILD AGED 6 OR YOUNGER, AND/OR A CURRENT PREGNANCY, THEN SCORE 1 FOR FAMILY SIZE.

FAMILY SIZE

SCORE:

Yes No Refused

Refused

Refused

In what language do you feel best able to express yourself?

Date of BirthParent 2 Age P2 Social Security P2

Social Security P1

CEA Assessment Packet for FAMILIES, page 11 of 16 (VI-SPDAT Questions 1-6)

assessor staff

assessment agency

(assessment date)

assessment location

Check dashed boxes to flag answers that don't appearaligned with individual's behavior or your knowledge of their situation

Flag

A. History of Housing and Homelessness5. Where do you and your family sleep most frequently? (check one)

Outdoors (location) Other (specify): Refused

IF THE PERSON ANSWERS ANYTHING OTHER THAN “SHELTER”, “TRANSITIONAL HOUSING”, OR “SAFE HAVEN”, THEN SCORE 1. SLEEP LOCATION SCORE A1:

6. How long has it been since you and your family lived inpermanent stable housing?

7. In the last three years, how many times have you and our familybeen homeless?

Refused

Refused

IF THE FAMILY HAS EXPERIENCED 1 OR MORE CONSECUTIVE YEARS OF CH SCORE A2:

Shelters Transitional Housing Safe Haven

HOMELESSNESS, AND/OR 4+ EPISODES OF HOMELESSNESS THEN SCORE 1.

B. Risks8. In the past six months, how many times has anyone in your family...

a) Received health care at an emergency department/room? Refused

b) Taken an ambulance to the hospital? Refused

c) Been hospitalized as an inpatient? Refused

d) Used a crisis service, including sexual assault crisis, mental health crisis,family/intimate violence, distress centers and suicide prevention hotlines?

Refused

e) Talked to police because they witnessed a crime, were the victim of a crime, or the al- leged perpetrator of a crime or because the police told them they must move along?

Refused

f) Stayed one or more nights in a holding cell, jail or prison, whether that was ashort-term stay like the drunk tank, a longer stay for a more serious offence, oranything in between?

IF THE TOTAL NUMBER OF INTERACTIONS EQUALS 4 OR MORE, THEN SCORE 1 FOR EMERGENCY SERVICE USE. RISK SCORE B1:

9. Have you or anyone in your family been attacked or beaten up sincethey’ve become homeless?

10. Have you or anyone in your family threatened to or tried to harm themself oranyone else in the last year?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF HARM.

Y N Refused

11. Do you or anyone in your family have any legal stuff going on right now thatmay result in them being locked up, having to pay fines, or that make it moredifficult to rent a place to live?

IF “YES,” THEN SCORE 1 FOR LEGAL ISSUES.

N

RISK SCORE B3:

12. Does anybody force or trick you or anyone in your family to do things thatthey do not want to do?

N Refused

13. Do you or anyone in your family ever do things that may be considered to berisky like exchange sex for money, run drugs for someone, have unprotectedsex with someone they don’t know, share a needle, or anything like that?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF EXPLOITATION. RISK SCORE B4:

Y Refused

Y N Refused

Y N Refused

Refused

TOTAL RISK SCORE B1+B2+B3+B4:

RISK SCORE B2:

total interactions


Y

C. Socialization & Daily Functioning14. Is there any person, past landlord, business, bookie, dealer, or government

group like the IRS that thinks you or anyone in your family owes them money?

Do you or anyone in your family get any money from the government, apension, an inheritance, working under the table, a regular job, or anythinglike that?

IF “YES” TO QUESTION 10 OR “NO” TO QUESTION 11, THEN SCORE 1 FOR MONEY MANAGEMENT.

SOCIAL SCORE C1:

Does everyone in your family have planned activities, other than just surviving, that make them feel happy and fufilled?

IF “NO,” THEN SCORE 1 FOR MEANINGFUL DAILY ACTIVITY. SOCIAL SCORE C2:

15.

16.

Y N Refused

Y N Refused

Y N Refused

Is everyone in your family currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other things like that?

IF “NO,” THEN SCORE 1 FOR SELF-CARE.

Is your family's current homelessness in any way caused by a relationship that broke down, an unhealthy or abusive relationship, or because other family or friends caused your family to become evicted?

IF “YES,” THEN SCORE 1 FOR SOCIAL RELATIONSHIPS.

SOCIAL SCORE C3:

C. Socialization & Daily Functioning (continued)

17.

18.

SOCIAL SCORE C4:

Y N Refused

Y N Refused

SOCIAL SCORE C1+C2+C3+C4:

Note: due to an oddity in Adobe/PDF, sometimes the last score won't tally until you click on the next answer. Complete Wellness Score 19 for Social Score to tally correctly


D. Wellness19. Has your family ever had to leave an apartment, shelter program, or other place

you were staying because of the physical health of you or anyone in your family?

20. Do you or anyone in your family have any chronic health issues with his/herliver, kidneys, stomach, lungs or heart?

21. If there was space available in a program that specifically assists people thatlive with HIV or AIDS, would that be of interest to you or anyone in your family?

Does anyone in your family have any physical disabilities that would limit the typeof housing you could access, or would make it hard to live independently becauseyou’d need help?

When someone in your family is sick or not feeling well, does yourfamily avoid getting medical help?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR PHYSICAL HEALTH. WELLNESS SCORE D1:

22.

23.

Has drinking or drug use by anyone in your family led your family family to be kicked out of an apartment or program where you were staying in the past?

25. Will drinking or drug use make it difficult for your family to stay housed orafford your housing?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR SUBSTANCE USE.

Y N

WELLNESS SCORE D2:

Has your family ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of:a) A mental health issue or concern?

b) A past head injury?c) A learning disability, developmental disability, or other impairment?

Does anyone in your family have any mental health or brain issues that would make it hard for your family to live independently because help would be needed?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR MENTAL HEALTH. WELLNESS SCORE D3:

24.

26.

27.

IF THE FAMILY SCORED 1 EACH FOR PHYSICAL HEALTH, SUBSTANCE USE AND MENTAL HEALTH: Does any single member of your household have a medical condition and mental health concerns and experience with problematic substance abuse

WELLNESS SCORE D4:

Y N Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Refused

Y Refused Y Refused

Y Refused

Y Refused

N

N

N

N

N

N

N

N

N 28.

IF “YES”, THEN SCORE 1 FOR TRI-MORBIDITY.

29. Are there any medications that a doctor said you or anyone in your familyshould be taking that, for whatever reason, they are not taking?

30. Are there any medications like painkillers that you or anyone in your familydon’t take the way the doctor prescribed or where they sell the themedication?

WELLNESS SCORE D5:

31 YES OR NO: Has your family's current period of homelessness beencaused by an experience of emotional, physical, psychological, sexual, or other type of abuse, or by any other trauma you or anyone in your have experienced?

IF “YES”, SCORE 1 FOR ABUSE AND TRAUMA.

IF "YES” TO ANY OF THE ABOVE, SCORE 1 FOR MEDICATIONS

Y N Refused

Y N Refused

Y Refused N

WELLNESS SCORE D6:

WELLNESS SCORE D1+D2+D3+D4+D5+D6:


Y RefusedN

E. Family Unit32. Are there any children that have been removed from the family by

a child protection service within the last 180 days?

33. Do you have any family legal issues that are being resolved in courtor need to be resolved in court that would impact your housing orwho may live within your housing?

IF “YES” TO ANY OF THE ABOVE, SCORE 1 FOR FAMILY LEGAL ISSUES. FAMILY UNIT SCORE E1:

34. In the last 180 days have any children lived with family or friendsbecause of your homelessness or housing situation?

35. Has any child in the family experienced abuse or trauma in the last180 days?

36. IF THERE ARE SCHOOL-AGED CHILDREN: Do your childrenattend school more often than not each week?

37. Have the members of your family changed in the last 180 days, due tothings like divorce, your kids coming back to live with you, someoneleaving for military service or incarceration, a relative moving in, oranything like that?

38. Do you anticipate any other adults or children coming to live withyou within the first 180 days of being housed?

IF “YES” TO ANY OF THE ABOVE, SCORE 1 FOR FAMILY STABILITY.

Y N

FAMILY UNIT SCORE E3:

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Refused

Y N Refused

Y N Refused


39. Do you have two or more planned activities each week as a family such as outingsto the park, going to the library, visiting other family, watching a family move, oranything like that?

40. After school, or on weekends or days when there isn’t school, is the total time childrenspend each day where there is no interaction with you or another responsible adult...

a) 3 or more hours per day for children aged 13 or older?

b) 2 or more hours per day for children aged 12 or younger?

41. I F THERE ARE CHILDREN BOTH 12 AND UNDER & 13 AND OVER:Do your older kids spend 2 or more hours on a typical day helping their younger sibling(s) with things like getting ready for school, helping with homework, making them dinner, bathing them, or anything like that?

IF “NO” TO QUESTION 39, OR “YES” TO ANY OF QUESTIONS 40 OR 41, SCORE 1 FOR PARENTAL ENGAGEMENT.

Y N Refused

Y N Refused

Y N Refused

Y N Refused


Due to an oddity in Adobe/PDF, type "done" in the field to the right to trigger the Family Unit calculation

FAMILY UNIT TOTAL SCORE E1+E2+E3+E4:


Scoring Summary by Domain SUBTOTAL

RESULTS

Score: Recommendation:

0-3: no housing intervention

4-8: an assessment for Rapid Re-Housing

9+: an assessment for Permanent Supportive Housing/Housing First

PRE SURVEY: AGE ƻŦ ŜƛǘƘŜǊ ǇŀǊŜƴǘ 60+

A. HISTORY OF HOUSING & HOMELESSNESSA1. Sleep ScoreA2. Chronic Homelessness Score

.. RISKS

C. SOCIALIZATION & DAILY FUNCTIONS

D. WELLNESS

GRAND TOTAL:

/1

/1

/4

/4

/6

/22

/1

E. FAMILY UNIT /4

FAMILY SIZE

/1

due to oddity in adobe/pdf, you'll need to type 'done' in the box to the right then hit tab key to trigger Grand Total Calculation

1-2: # kids

Under 18

3: Pregnant female

5: where Sleep

6: how long since perm hsg

7: # times homeless last 3 yrs

8a: ER visits

past 6 mo

8b: ambu-lance

past 6 mo

8c: in patient

past 6 mo

8d: crisis svcs

past 6 mo 8e: police

interaction past 6 mo

8f: # times holding

cell

9: attacked 10: threaten / harm

-self/others

11: legal stuff

12: forced or tricked

13: risky behavior

14: owe $$

15 receive $$

16: planned activities

17: care for basic

needs

18: H/L caused by

relationship

19: left hsg due to phys-

ical health

20: Chronic health

conditions

21: accept HIV

housing

22: disabilities limit

hsg options

23: when sick, avoid

care

24: SA led to H/L

25: SA still a

factor 26a: lost

housing due to MH

26b: lost housing

due to TBI

26c: lost housing

due toLD/DD

27: MH brain issues hard to live

independent

29: Meds not taking

sold, not taken as prescribed

31: H/L caused

by trauma

32: children removed

by CPS last 180 days

33: legal issues

who may live with you

34: children Live with

fam/friend due to H/L

35: child experienced

trauma past 180 days

36:children attend

school

37: family membership

changes past 180 days

38: family members

joining first 180 days

39: 2+ plan family

activities each week

40a: >3 hrs no adult contact

child age >13

40b: >2 hrs no adult contact

child age <12

41: older kids care

for young siblings

>2 hrs/day

30: Meds

28: Any family

membertri-morbidity

CLOSING SCRIPT: Thank you for completing this assessment. I will enter this into HMIS / the King County Coordinated Entry list of people who need housing and services. This list is prioritized, with a goal to house those with the most severe needs and longest periods of homelessness first. We know from experience that many more people need housing than available units, so we can't provide definite estimates when you'll rise to the top of the list - much of it depends on a mix of eligibility criteria - and you should continue to seek housing on your own. If/when you do rise to the top of a list, you would get a call from one of our partners such as Community Psychiatric Clinic, Catholic Community Services, YWCA, the VA, or King County Coordinated Entry referral specialists. Let's review your contact information. [Assessor - check phone/email from page 6]

General Notes

VI-SPDAT Assessor Flag Assessment flagged as part of CEA Housing Assessment Disability Accommodation

Assessor F Name

Assessor Aglency Survey Location

Assessor Last Name

ASSESSOR QUALITY CONTROLI confirm that this client's consent status (Release of Information) has been documented in HMIS under their privacy shield. Initial Here:

COMPLETED and ENTERED SIGNED, ON FILE (and Uploaded to HMIS for those consenting to identification in HMIS)

CEA/HMIS Consent and Release of Information (all household members >age 18)

VA Release of Information (if a Veteran)

HUD Universal Data Elements CEA Supplemental Questions VI-SPDAT

RAP Staff?

Flag Notes:

CEA Assessment Packet for FAMILIES, page 16 of 16 (VI-SPDAT Scoring 4/4 + close out + Flags)

VI-SPDAT and Supplemental Questions for individuals ... · PDF fileOMB Number: 290090260 ....

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Transcript of VI-SPDAT and Supplemental Questions for individuals ... · PDF fileOMB Number: 290090260 ....