Basic Information

Legal Name

First*

Middle

Last*

Social Security No.*Client Support Specialist*

Date*Agency/Program*

Services Requested

Services Requested at Intake (check all that apply):

Personal Information

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

Do you speak and understand English?*

YesNo

If no, what language are you most comfortable speaking?

SpanishChineseVietnameseArabicOther

Who referred you to this program?

Name

Maiden name

Other names known by

Personal Information, cont'd.

Are you the head of the household?YesNo

How many children in the household?

Total household size?

Phone no. (if any)

Email (if any)

ID number

For HOPWA Programs

Are you currently taking any medications?YesNoIf yes, what type of medications?

Income and Employment

Are you employed?YesNo

If employed, type of employment?Full-timePart-timeSeasonal

How many hours do you work each week?

Where?

If unemployed, why?Looking for workUnable to workNot lookingOther:

Any income received from any source in the last 30 days?YesNo

Income and Employment, cont'd.

Current total monthly income (for self and dependents under 18): $

Are you eligible for public assistance you are not currently receiving?YesNoUnsureHave you lost any of the following public assistance in the last year? If so, why did you lose your public assistance?

Education

Last grade completed?Did you graduate from high school, get a GED, or certificate of high school proficiency?YesNo

Criminal History / Police Contact

Have you ever been convicted of a felony?YesNo

Have you ever been convicted of a crime?YesNo

Were you convicted within the last six months?YesNo

Are you currently on probation?YesNoProbation end date: Probation officer's name and phone no.

Are you currently on parole?YesNoParole end date:

Parole officer's name and phone no.

Have you ever been incarcerated in State/County/Federal Prison?YesNo

If yes:

Were you released as a result of California Assembly Bill (AB) 109?YesNo

Were you released within the last six months?YesNo

Have you ever been held in city or county jail?YesNo

If yes, were you held there within the last six months?YesNo

How many times within last 6 months?

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

Chronic Homelessness

Are you entering from the streets, shelter, or safe haven?YesNoDeclined

If yes, approximate date this episode of homelessness started (breaks of 7 days 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.

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. Total Number of Months Homeless in the Past Three Years: Total length of time you have been homeless(without housing) [Short breaks are acceptable.]

years

months

Don't knowDeclined

Is your length of homelessness documented, either in HMIS or in a paper file?YesNoDeclined

Insurance

Do you currently have insurance?YesNo

If yes, please provide informationDo any of the below apply? (check and provide information)

Health and Disability

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

Have you ever been a victim of domestic violence? YesNoDon't knowDeclined

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

Are you currently fleeing?YesNoDon't knowDeclined

Health and Disability, cont'd.

Are you currently covered by health insurance?YesNoDon't KnowDeclined

Please answer Yes or No for each of the following health insurance types:

Signature

All information on this page is required.

Enter your name:I certify that all information entered on this form is true & correct.

Did anyone assist you in filling out this form?YesNo

If yes, enter their name:Date

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