RHY SOP Intake Entry Exit - nh

Transcription

New Hampshire Continua of Care
RHY Street Outreach Program (SOP) Entry/Exit Form for HMIS
HUD requires this form to be completed for each client entering or exiting your project.
SOP Manchester
 SOP Seacoast
Refer to the 2014 HUD HMIS Data Standards, available on the NH-HMIS website www.nh-hmis.org for an
explanation of the data elements in this form.
Date Form Completed: __ __/ __ __/ __ __ __ __
Outreach Worker for NH: __________________________
Outreach City/Town: ______________________________
First, MI, Last Name, Suffix:
 Full name reported
 Partial, street name, or code name reported
 Client doesn’t know
 Client refused
 Data not collected
Name Data Quality:
Alias:
Client ID Number:
Household ID Number (optional):
Client ID number is generated by the HMIS system.
Household ID number is generated by the HMIS system.
Client Record Creation
SSN: __ __ __ - __ __ - __ __ __ __

SSN Data Quality:  Full SSN Reported
 Client Refused
U.S. Military Veteran?  No
 Yes
 Client Does Not Know or Does Not Have SSN
 Data not collected
 Partial SSN Reported 
 Client refused  Data not collected
Discharge Type:  Honorable  Uncharacterized  Dishonorable
 General under honorable conditions
 Bad Conduct  Under other than honorable conditions (OTH)
 Client Doesn’t Know
 Client Refused

Date of Birth:
/
/
 Full DOB Reported
Date of Birth Type:  Approximate or Partial DOB Reported
 Client Refused
Race (client may choose up to 5) :
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
Ethnicity (choose one):  Hispanic/Latino  Non-Hispanic/Non-Latino
 Data not collected
Gender:  Female
 Male
  Client Doesn’t Know  Client Refused
04/14/2015
 Client Refused
 Client Refused
 Transgender Female to Male  Transgender Male to Female
 Other, (specify) ____________________  Data not collected
RHY SOP Intake Entry/Exit Form Revision A
New Hampshire Homeless Management Information System (NH-HMIS)
Page 1 of 11
Entry Assessment
Click Add Entry/Exit. Click to open the Type drop down menu, then select RHY. Click Save and Continue.
Relationship to Head of Household (HoH) (choose one):
 Self
 Head of household’s child
 Head of household’s spouse or partner
 Head of household’s other relation member (other relation to HoH)
 Other: non-relation member __________________________
Outreach
Location (choose one):
 Place not meant for habitation
 Service setting, non-residential
 Service setting, residential
Start Date: ______/______/_________
End Date: ______/______/_________
Date of Contact: ______/______/_________ Time of Contact (Optional)
:
AM PM (Circle one)
Entry Disability
 No  Yes  Client Doesn’t Know  Client Refused
Information/ Project Entry Date: ____/____/______
Disability Start Date ____/____/______
Disability End Date ____/____/______
Does the client have a disabling condition?
If Yes:
Disability Type
 Physical Disability
 Developmental Disability
 Chronic Health Condition
 HIV/AIDS
 Mental Health Problem
 Substance Abuse Problem
 Alcohol Abuse
 Drug Abuse
  Both Alcohol &
Drug Abuse
If yes, expected to be of longcontinued and indefinite duration
and substantially impairs ability to
live independently?
No Yes  CDK  CR  DNC
(If yes) Documentation of the
disability and severity on file?
No
No
No
No
No
No
No
No
No
Yes  CDK  CR  DNC
(If yes) Currently Receiving
Services or Treatment?
No
No
No
No
No
No
No
No
No
Disability Note (optional information about disability):
Will above condition be long term?  No
04/14/2015
 Yes
Page 2 of 11
Residence Prior to Project Entry (where client stayed the night before project entry):

 Emergency shelter, including hotel or motel paid with emergency
shelter voucher
 Foster care home or foster care group home
 Hospital or other residential non-psychiatric medical facility
 Hotel or motel paid for without emergency shelter voucher
 Jail, prison or juvenile detention facility
 Long-term care facility or nursing home
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons (such as:
CoC project; HUD legacy programs, or HOPWA PH)
 Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere outside)
 Psychiatric hospital or other psychiatric facility

 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other (non-VASH) ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living in a family member’s room, apartment or house
 Staying or living in a friend’s room, apartment or house
 Substance abuse treatment facility or detox center
 Transitional housing for homeless persons (including homeless youth)
 Client refused
 Other (specify) ___________________________________
Length of Stay in Previous Place (choose one):
 One day or less
 Two days to one week
 More than one week, but less than one month
 One to three months
 More than three months, but less than one year
 One year or longer
 Client refused
 NH-500 (Balance of State/Concord)
 NH-501 (Manchester)
 NH-502 (Nashua)
Length of time on street, in an Emergency Shelter, or Safe Haven:
Client Location (choose one HUD-assigned CoC Code):
 Continuously homeless for at least one year?
No
Yes
Client doesn’t know
Client refused
 Number of times the client has been homeless in the past three years
0
1
2
 3
4 or more
Data not collected
 Client refused
 If 4 or more, total number of months homeless in the past three years ____
 More than 12 months
Client doesn’t know
Client refused
 Total number of months continuously homeless immediately prior to project entry ____
Note: 1 day to 30 days = 1 month. For example, a client living on the street from mid-July to the day the client enters
emergency shelter on August 5th. This would count as two months.
 Status Documented No
Yes
Note: Indicate if there is documentation in the client’s paper file or in the HMIS of the client’s length of homelessness –
either continuously homeless, the number of times homeless, or the number of months homeless in the past
three years.
04/14/2015
Page 3 of 11
Sexual Orientation
Heterosexual
Gay
Lesbian
Bisexual
Questioning/Unsure
Client Doesn’t know
Client Refused
Data Not Collected
Entry Health Insurance
In ServicePoint, click to select the Entry/Exit tab.
Covered by health insurance?
 No  Yes  Client doesn’t know
If yes, Information/ Project Entry Date: ______/______/________
Health Insurance Source:
If Yes, choose No or Yes below and add dates.
Health Insurance Source
Start Date
End Date
No Yes
No Yes
MEDICAID
MEDICARE
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
State Children’s Health Insurance Program
____/____/______
____/____/______
No Yes
Veteran’s Administration (VA) Medical Services
____/____/______
____/____/______
No Yes
No Yes
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
Private pay health insurance
No Yes
State Health Insurance for Adults
____/____/______
____/____/______
____/____/______
____/____/______
Domestic Violence Victim/Survivor?
 No
 Yes
 Client refused
04/14/2015
If yes, When Experience Occurred:
 Within the past 3 months  More than a year
 3 - 6 months ago
 6 - 12 months ago
 Client refused
Page 4 of 11
Pregnancy Status
No
Yes
If yes, Due Date: _____/______/_________
Client doesn’t know
Client refused
Commercial Sexual Exploitation
Have you received something in exchange for sex
in the past three months?
No
Yes
Client doesn’t know
Client refused 
Data not collected
If Yes:
Number of times:

If Yes:

Did someone ask/make you
have sex?

04/14/2015
1-3
4-7
8-30
More than 30
Client doesn't know
Client refused
Data not collected
Yes
No
Data not collected

Page 5 of 11
Information Required by BHHS
Housing Status as of the day before project entry:
Homeless and At-Risk of Homelessness Status
 Category 1 – Homeless (lacks fixed, regular, and adequate nighttime residence)
 Category 2 – At imminent risk of losing housing (will lose primary nighttime residence in 14 days)
 Category 3 – Homeless only under other federal statues (unaccompanied youth under 25 years of age, or families with
children and youth, who do not otherwise qualify as homeless under this definition)
 Category 4 – Fleeing domestic violence (when client or household does NOT meet any other criteria but is homeless solely
because they are fleeing domestic violence)
 At-risk of homelessness (for clients being served by Homelessness Prevention or Coordinated Assessment projects)
 Stably housed
Zip Code data quality:
 Full or Partial
 Client Doesn’t Know  Client Refused
 Data not collected
Zip Code of Last Permanent Address:
(where client last lived 90 days or more)
Entry Employment Status
Employment status is a required element per NH BHHS.
Information Date _____/______/________
Employed?
Yes
If Yes, type of employment?
Full time
Part time

No
Homeless Status
First Time Homeless?
Yes
No
04/14/2015
Page 6 of 11
Services Provided
In ServicePoint, click to select the Service Transaction tab.
Service
Service Date
Street Outreach- Health and Hygiene Products Distributed
______/______/_________
Street Outreach- Food And Drink Items
______/______/_________
Street Outreach- Services Information/Brochures
______/______/_________
Referrals Provided
In ServicePoint, click to select the Service Transaction tab.
Referral
Referral Date
Child Care Non-TANF
______/______/_________
Supplemental Nutritional Assistance Program (Food Stamps)
______/______/_________
Education-McKinney/Vento Liaison Assistance to Remain in School
______/______/_________
HUD Section 8 or Other Permanent Housing Assistance
______/______/_________
Individual Development Account
______/______/_________
Medicaid
______/______/_________
Mentoring Program Other Than RHY Agency
______/______/_________
National Service (AmeriCorps, VISTA, Learn and Serve)
______/______/_________
Non-residential Substance Abuse or Mental Health Program
______/______/_________
Other Public-Federal, State or Local Program
______/______/_________
Private Non-profit Charity or Foundation Support
______/______/_________
SCHIP
______/______/_________
SSI, SSDI or other Disability Insurance
______/______/_________
TANF or other Welfare/Non-disability Income Maintenance (all TANF)
services
______/______/_________
Unemployment Insurance
______/______/_________
WIC
______/______/_________
Workforce Development (WIA)
______/______/_________
04/14/2015
Page 7 of 11
EXIT Data
Exit Reason for Leaving and Destination
In ServicePoint, click to select the Entry/Exit tab
Exit Date: ____/____/________
Reason for leaving (choose one):
 Completed program
 Criminal activity/violence
 Death
 Unknown/Disappeared
 Disagreement with rules/persons
 Non-compliance with program
 Housing opportunity before completing
 Non-payment of rent
 Needs could not be met
 Reached maximum time allowed
 Other (specify)___________________________________________________
Destination (choose one):
 Deceased
 Emergency shelter, including hotel or motel paid with
emergency shelter voucher
 Foster care home or foster care group home
 Hospital or other residential non-psychiatric medical
facility)
 Hotel or motel paid for without emergency shelter voucher
 Jail, prison or juvenile detention facility
 Long-term care facility or nursing home
 Moved from one HOPWA funded project to HOPWA - PH
 Moved from one HOPWA funded project to HOPWA - TH
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons (such as:
CoC project; HUD legacy programs, or HOPWA PH)
 Place not meant for habitation (e.g., a vehicle, an abandoned
building, bus/train/subway station/airport or anywhere
outside)
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living with family, permanent tenure
 Staying or living with family, temporary tenure (e.g., room,
apartment or house)
 Staying or living with friends, permanent tenure
 Staying or living with friends, temporary tenure (e.g., room,
apartment or house)
 Substance abuse treatment facility or detox center
 Transitional housing for homeless persons (including homeless
youth)
 No exit interview completed
Exit Date of Engagement : ____/____/________
Optional: If client exits without becoming engaged, the engagement date should be left blank.
04/14/2015
Page 8 of 11
Exit Health Insurance
In ServicePoint, click to select the Entry/Exit tab.
Covered by health insurance?
 No  Yes  Client doesn’t know
If yes, Information/ Project Entry Date: ______/______/________
Health Insurance Source:
If Yes, choose No or Yes below and add dates.
Health Insurance Source
Start Date
End Date
No Yes
No Yes
MEDICAID
MEDICARE
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
State Children’s Health Insurance Program
____/____/______
____/____/______
No Yes
Veteran’s Administration (VA) Medical Services
____/____/______
____/____/______
No Yes
No Yes
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
____/____/______
____/____/______
____/____/______
____/____/______
No Yes
Private pay health insurance
No Yes
State Health Insurance for Adults
____/____/______
____/____/______
____/____/______
____/____/______
Exit Disability
 No  Yes  Client Doesn’t Know  Client Refused
Information/ Project Entry Date: ____/____/______
Disability Start Date ____/____/______
Disability End Date ____/____/______
Does the client have a disabling condition?
If Yes:
Disability Type
 Physical Disability
 Developmental Disability
 Chronic Health Condition
 HIV/AIDS
 Mental Health Problem
 Substance Abuse Problem
 Alcohol Abuse
 Drug Abuse
  Both Alcohol &
Drug Abuse
If yes, expected to be of longcontinued and indefinite duration
and substantially impairs ability to
live independently?
(If yes) Documentation of the
disability and severity on file?
No
No
No
No
No
No
No
No
No
(If yes) Currently Receiving
Services or Treatment?
No
No
No
No
No
No
No
No
No
Disability Note (optional information about disability):
Will above condition be long term?  No
04/14/2015
 Yes
Page 9 of 11
Information Required by BHHS
Housing Status as of the day before project entry:
Homeless and At-Risk of Homelessness Status
 Category 1 – Homeless (lacks fixed, regular, and adequate nighttime residence)
 Category 2 – At imminent risk of losing housing (will lose primary nighttime residence in 14 days)
 Category 3 – Homeless only under other federal statues (unaccompanied youth under 25 years of age, or families with
children and youth, who do not otherwise qualify as homeless under this definition)
 Category 4 – Fleeing domestic violence (when client or household does NOT meet any other criteria but is homeless solely
because they are fleeing domestic violence)
 At-risk of homelessness (for clients being served by Homelessness Prevention or Coordinated Assessment projects)
 Stably housed
Exit Employment Status
Employment status is a required element per NH BHHS.
Information Date _____/______/________
Employed?
Yes
If Yes, type of employment?
Full time
Part time

No
04/14/2015
Page 10 of 11
Fill out this section to help identify a client’s common household members. This information is entered at client program entry.
Head of Household
Is this person the head of a household (households can have only one HoH):
 Yes
 No
If Yes to previous question, please list other members of the household and their relationship to the head of household.
First Name
Last Name
Relationship to Head of
Household*
*CHOOSE:
 Self (head of household)
 Head of household’s child
 Head of household’s spouse or partner
 Head of household’s other relation member (other relation to head of household)
 Other: non-relation member
Important! Please complete the SOP Intake Entry/Exit Form for each person listed above.
This form can be found on the NH-HMIS website at www.nh-hmis.org.
04/14/2015
Page 11 of 11

RHY SOP Intake Entry Exit - nh

Transcription

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