Montgomery County Assessment Tool - WP Engine

Montgomery County Assessment Tool - WP Engine

Montgomery County Front Door Intake Last Name of Head of First Name: Household: DOB: Age: Describe the circumstances that led you to come here today: ...

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Montgomery County Front Door Intake Last Name of Head of First Name: Household: DOB: Age: Describe the circumstances that led you to come here today:

Today’s Date:

Middle Initial SSN:

______________________________________________________________________________________________ ______________________________________________________________________________________________ What do you need right now? ______________________________________________________________________________________________ What is your plan for leaving the shelter?______________________________________________________________

HOUSEHOLD TYPE __ Single Adult __ Female Single Parent ___Male Single Parent ___Two Parent Family ___Foster Parent __ Two or More Adults with no children <18 __Grandparent and Child __Non-custodial care giver __Other: Number in Household: No. of Adults _____ No. of Children _____ Marital Status of Head of Household: married  separated 

divorced 

single 

Housing Status Category 1-Homeless Category 2- At Imminent risk of losing housing Category 3-Homeless only under other federal status Category 4-Fleeing domestic violence At-risk of homelessness Stably housed Client doesn’t know Client refused

HOUSEHOLD INFORMATION List information about the people in your current household. Please start with the Head of Household (HOH): First Name

Last Name

Gender

DOB

SSN

Relationshi p to HOH*

Custody if Child <18, Y or N

Veteran Y or N

Race

Ethnicity **

Disabled (Y or N)

1.Head of Household 2. 3.

4. 5.

*Relationship to Head of Household: choose: self, spouse, partner, son, daughter, mother, father, sister, brother, grandparent ** Ethnicity: enter Hispanic/Latino [H/L] or Non-Hispanic/Latino [NHL] Phone/Email for Household: (Repeat as necessary) Name:

Phone Number:

Email:

Emergency Contact: Name: Street Address:

Phone:

Relationship: pick from * list above City, State, Zip: 1|Page

Montgomery County Front Door Intake HOUSING ARRANGEMENTS: WHERE DID YOU STAY THE LAST NIGHT (before shelter)? Street Address:

City

State

Facility or Program Name (if Applicable)

Zip

Monthly Cost to Live There: $

How long were you staying there? (Choose one)  One week or less  More than one week, but less than one month  More than three months, but less than one year  One year or longer

 One to three months  Don’t Know

Type of Housing/Accommodation: (Choose one) Rental by client, no housing subsidy Emergency Shelter, including hotel or motel paid for with Rental by client, with VASH housing subsidy emergency shelter voucher Rental by client, with other (non-VASH) housing Hotel or motel paid without emergency shelter voucher subsidy Transitional housing for homeless persons (including Owned by client, no housing subsidy homeless youth) Owned by client, with housing subsidy Safe Haven Staying or living in a family member’s room, Psychiatric Facility apartment or house Substance Abuse treatment facility or detox center Staying or living in a friends room, apartment or Hospital or other non-psychiatric medical facility house Jail, prison, juvenile detention facility Foster care home or foster care group home Place not meant for habitation (e.g. a car, abandoned bldg., Permanent housing for formerly homeless persons bus/train/subway station/airport or anywhere outside) (such as SHP, S+C, SRO) Rental by Client, with GPD TIP subsidy Long term care facility or nursing home Don’t know Residential project or halfway house with no Other homeless criteria Type of Housing Subsidy (if applicable):  HAP  GDPM  ESPG  Section 8  S+C  SHP  VA Supportive Housing (VASH) None

Other:

What is the PRIMARY reason you left this housing? (Choose One)  Eviction  Unable to pay rent  Utility shut off  Domestic Violence  Unsafe situation  Fire  Condemned property  Foreclosure (renter)  Foreclosure (owner)  Overcrowded  Conflict with others  Moved from out of town Discharge from program  Physical illness  Discharge from hospital  Jail or Prison release  Substance Use Mental Illness Other (please describe): If you are being evicted, do you have a court date?  Yes  No Date you need to leave: month/day If you were staying with family or friends, could you safely stay there if we offered you some help?  Yes  No If yes, explain: _______________________________________________________________________________ Conditions under which you could return to the place you stayed last night: ______________________________________________________________________________________________ ______________________________________________________________________________________________

LAST PERMANENT RESIDENCE (if different from where you stayed last night) Street Address:

City

Facility or Program Name (if Applicable)

State

Zip

Monthly Cost to Live There: $

How long were you staying there? (Choose one)  One week or less  More than one week, but less than one month

 One to three months

 More than three months, but less than one year

 Don’t Know

 One year or longer

1/9/15 Page 2

Montgomery County Front Door Intake Type of Housing/Accommodation: (Choose one) Rental by client, no housing subsidy Emergency Shelter, including hotel or motel paid for with Rental by client, with VASH housing subsidy emergency shelter voucher Rental by client, with other (non-VASH) housing Hotel or motel paid without emergency shelter voucher subsidy Transitional housing for homeless persons (including Owned by client, no housing subsidy homeless youth) Owned by client, with housing subsidy Safe Haven Staying or living in a family member’s room, Psychiatric Facility apartment or house Substance Abuse treatment facility or detox center Staying or living in a friends room, apartment or Hospital or other non-psychiatric medical facility house Jail, prison, juvenile detention facility Foster care home or foster care group home Place not meant for habitation (e.g. a car, abandoned bldg., Permanent housing for formerly homeless persons bus/train/subway station/airport or anywhere outside) (such as SHP, S+C, SRO) Rental by Client, with GPD TIP subsidy Long term care facility or nursing home Don’t know Residential project or halfway house with no Other homeless criteria Type of Housing Subsidy (if applicable):  HAP  GDPM  ESPG  Section 8  S+C  SHP  VA Supportive Housing (VASH) None

Other:

What is the PRIMARY reason you left this housing? (Choose one)  Evicted  Unable to pay rent  Utility shut off  Domestic Violence  Unsafe situation  Fire  Condemned property  Foreclosure (renter)  Foreclosure (owner)  Overcrowded  Conflict with others  Moved from out of town Discharge from program  Physical illness  Discharge from hospital  Jail or Prison release  Substance Use Mental Illness Other (please describe):



If you were staying with family or friends, could you safely stay there if we offered you some help?  Yes  No If yes, explain: ______________________________________________________________________________ Conditions under which you could return: ______________________________________________________________________________________________ ______________________________________________________________________________________________

HOUSEHOLD INCOME How much is your total monthly household income? $ Have you had any change in your household income in the last three months?  Yes  No If yes, please describe: Have you had any significant increases in household expenses over the last three months?  Yes  No If yes, please describe: Please list all sources and amounts of monthly income for each adult 18 years or older in the household: Head of Household Info

First Name:

Income Source Earned/Employment Income Unemployment Income Supplemental Security Income (SSI) Social Security Disability Income (SSDI) VA Service Connected Disability VA Non Service Connected Disability Private Disability Insurance Workers Compensation Non Cash Benefits You Receive Food Stamps TANF Child Care Services TANF Transportation Services

Last Name:

Amount

Income Source

Amount

TANF General Assistance Retirement Income From Social Security Pension from Retirement Child Support Alimony or Other Spousal Report No financial resources

 Yes  No  Yes  No  Yes  No

Other TANF-funded Services Section 8, public housing or other subsidy

 Yes  No  Yes  No 1/9/15

Page 3

Montgomery County Front Door Intake Health Insurance You Receive Covered by Health Insurance (If yes indicate all  Yes  No VA Medical Services  Yes  No sources that apply) Medicaid  Yes  No Health insurance obtained through COBRA  Yes  No Medicare  Yes  No Private Health Insurance  Yes  No State Health Insurance for Adults  Yes  No Other:  Yes  No State Health Insurance  Yes  No Other:  Yes  No Do you have a Bank Account?  Yes  No Checking $ _________ Savings $___________ Other $___________ Do you have any assets (e.g., car, property, CD, IRA, 401K)?  Yes  No Other Relevant Information on income or assets: ___________________________________________________

Do you have any debts? Yes No - List totals Utilities $________ Credit Card $_________ Medical Bills $_________ Car $________Overdue Child Support $ Rent $ ________ Mortgage $ ___________ Gambling $__________ IRS$ Other: $________ Do you owe money to GDPM Yes No Total owed: $ Are your wages being garnished? Yes No If yes, what amount per month? _____________________________ If you pay child support, monthly amount? ________ Back payment amount? ________ Total Monthly debts $ Please list all sources and amounts of monthly income for each adult 18 years or older in the household: Next Adult

First Name:

Income Source Earned/Employment Income Unemployment Income Supplemental Security Income (SSI) Social Security Disability Income (SSDI) Veteran’s Disability Non-service connected disability Private Disability Insurance Worker’s Compensation TANF Non Cash Benefits Received Food Stamps TANF Child Care Services TANF Transportation Services Health Insurance You Receive Covered by Health Insurance (If yes indicate all sources that apply) Medicaid Medicare State Health Insurance for Adults State Health Insurance

Last Name Monthly Amount

Income Source

Amount

General Assistance Retirement Income from Social Security Child Support Alimony or other spousal support Unemployment Insurance VA service connected disability Pension or retirement income No financial resources  Yes  No  Yes  No  Yes  No

Other TANF-funded Services Section 8, public housing or other subsidy Special Supplemental Nutrition Program

 Yes  No  Yes  No  Yes  No

 Yes  No

VA Medical Services

 Yes  No

 Yes  No  Yes  No

Health insurance obtained through COBRA Private Health Insurance

 Yes  No

 Yes  No

Other: Other:

 Yes  No  Yes  No  Yes  No

Do you have a Bank Account?  Yes  No Checking $ _________ Savings $___________ Other $___________ Do you have any assets (e.g., car, property, CD, IRA, 401K)?  Yes  No Other Relevant Information on income or assets: ___________________________________________________ Do you have any debts? Yes No - List totals Utilities $________ Credit Card $_________ Medical Bills $_________ Car $________Overdue Child Support $ Rent $ ____________ Mortgage $ ____________ Gambling $__________IRS $ Other: $________

Do you owe money to GDPM Yes No Total owed: $ Are your wages being garnished? Yes No If yes, what amount per month? __________________________ If you pay child support, monthly amount? ________ Back payment amount? ________ Total Monthly debts $ Repeat above information as needed.

1/9/15 Page 4

Montgomery County Front Door Intake SUPPORTS/INDEPENDENT LIVING Has anyone been helping you recently? Yes  No Name:

Relationship ____________________________________

Organization/Affiliation:

_____________________________________

Phone #_______________________________ If anyone has been helping you, is there anyone you might be able to stay with temporarily? Yes  No If yes, Name: ____________________________________________ Could you stay with this person while we work to help you find a more permanent place to live? If yes, can you safely stay there?  Yes  No

 Yes  No

What do you think it would take to arrange to stay with this person or family? Explain:_____________________________________________________________________________________ Do you have a case manager at another agency?  Yes  No If Yes, Name: ________________________ Agency: ___________________ Phone: ___________________ Do you have an open case with Children’s Services?  Yes  No If Yes, Worker Name:_________________________ Phone: _____________________ If you are receiving benefits like Social Security or SSI, do you have a representative payee?  Yes  No If yes, Name:

Relationship:

Phone number:

If you are a member of your household is a Veteran, type of discharge:  Honorable  General  Other than Honorable

 Bad Conduct

 Dishonorable

Do you have a disabling condition that prevents you from working or functioning well?  Yes  No  Unknown Please describe: Have you been homeless in the last year?  Yes  No Have you been continuously homeless for at least one year?  Yes  No How many times has client been homeless in the past three years? 1(homeless only this time)  2 times 3 times 4 times If 4 or more number of months homeless in the last 3 years Is client chronically homeless  Yes  No Do you have a physical disability that limits your mobility?  Yes  No  Unknown Please describe: Are there any restrictions on where you can live?  Yes  No If yes, please describe: Do you have any legal issues?  Yes  No If yes, please describe: Are you on  Parole Probation? If so, what was the offense? Is anyone in the household pregnant?  Yes  No If yes, Name: Due Date: month/year Do you have Government Issued ID for the head of household?  Yes  No If Yes, check all that you have:  Driver’s License  Birth Certificate  Passport  Green Card  Other Government Issued ID “What Schools are your children enrolled in?” Repeat as needed for multiple children Child’s Name: School Name: Location: Grade:

RISK ASSESSMENT (Refer to your agency’ protocol for risk assessment) Are you or anyone in your family on any federal or state sex offender registry?  Yes  No If yes, describe: narrative text box – up to 2500 characters Observations of mental state – Intoxicated? Disorganized? Disoriented : Health issues – current distress – bleeding, chest pains, nausea, etc.?  Yes  No 1/9/15 Page 5

Montgomery County Front Door Intake Current Medications?  Yes  No Do you have medications with you?  Yes  No Acute suicidal/homicidal/medical issues? (Use agency suicide assessment protocol) Need for Emergency Services?  Yes  No Notes/summary

 Yes  No

DIVERSION PLAN (if applicable): Describe: Street Address:

City, State, Zip Code:

Telephone #: Diversion Type:  Own Apt Psychiatric Hospitalization

 With Family  With Friends  Medical Hospitalization  Hotel/Motel  Other:

 Detox



Front Door Comprehensive Assessment Domains* Housing History – Last 5 years Name/Location

Type

Start

End Date

Pick list from Pg. 2        

Leaseholder Yes or No

Reason for Leaving Pick list from page 2

Ever evicted from GDPM housing? Y or N Restrictions on where can live Y or N with narrative explanation Was the head of household ever in foster care Y or N Barriers to Housing Stability (pick list and then space for “other” with a text box.) Pick list: Trouble budgeting, visitors create problems, involved in illegal activity, no experience as lease holder Housing Plan Who do you plan to have living with you when you leave here? Name : Age Relationship Gender M/F (Allow multiple entries) Housing Goals Motivation to Obtain Housing: High, Medium, Low

Employment History – Last 5 Years Employer

   

Position/Title

Wage

Start

End

Reason for Leaving Pick List Better job Quit Fired Laid Off Other:

Employment Goals Services currently receiving Services Needed to Access or Maintain Employment Motivation to obtain employment: Pick High, Medium or Low

Benefits and Entitlements  Status – pull from previous income screen and add start and end dates Income Receiving Earned/Employment Income Unemployment Income Social Security Income (SSI)

Start Date/ End Date

Income Source Workers Compensation TANF General Assistance

Start Date/ End Date

1/9/15 Page 6

Front Door Comprehensive Assessment Domains* Social Security Disability Income (SSDI) Retirement Income from Social Security VA Service Connected Disability Pension From Retirement VA Non Service Connected Disability Child Support Private Disability Insurance Alimony or other spousal report  Plan to apply for or maintain income benefits – text boxes for tasks and separate box for whose responsibility it is. Allow multiple tasks  Task  Responsible Party Noncash Benefits – Pre-populate from Y or N Y or N intake assessment Food Stamps Y or N Section 8, public housing or subsidy Y or N TANF Child Care Services Y or N Other TANF-funded Services Y or N Special Supplemental Nutrition Program Y or N Other: (list) Y or N Health Insurance You Receive Covered by Health Insurance (If yes, indicate Y or N VA Medical Services Y or N all sources that apply) Medicaid Y or N Health Insurance Obtained by COBRA Y or N Medicare Y or N Private Health Insurance State Health Insurance for Adults State Health Insurance  Plan to apply for or maintain noncash benefits – Allow multiple tasks  Task  Responsible Party  Barriers to Obtaining/Maintaining Entitlements:

Debts  Credit Status/Score Car Child Support(Back payment) Child Support (Monthly payment) Credit Card GDPM Gambling Garnished Wage IRS Medical Bills Mortgage Rent Utilities  Plan to pay off debts  Services Needed  Motivation to resolve credit/debt issues: Pick High, Medium or Low  Goals

Legal  Legal Resident Y or N  Probation/Parole Status to pre-populate from Intake Assessment  Name of PO: Date Supervision Ends Felony history for last 5 years: Date Charge/Crime Conviction: Pick Yes or No

Incarceration history for last 10 years: Start Date End Date

Facility

Reason/Charge

Brief narrative summary of involvement in the legal system: (Maximum 2500 characters)  Current involvement – e.g., engaging in criminal activity, current legal proceedings, outstanding warrants, subject to order of protection, etc.  Child support enforcement status  Goals  Services Needed  Motivation to resolve legal issues: Pick High, Medium or Low

Education History Highest Grade Completed:  Some HS Last Grade completed : HS Diploma or GED Some College  Associate’s Degree Bachelor Degree  Technical Certification - Field: Other



Current status  In school Name of School:



 Applying Education Goals



Services Requested

Expected date of Enrollment: month/year

1/9/15 Page 7

Front Door Comprehensive Assessment Domains* Physical and Behavioral Health 



Where do you usually go for healthcare or when you’re not feeling well? [pick specific hospital or clinic]  Community Health Centers of Greater Dayton  Charles Drew  Corwin Nixon  East Dayton  Miami Valley Hospital  Grandview Hospital  Good Samaritan Hospital  Samaritan Clinic/Health Care for the Homeless Clinic  Private doctor  VA  Fiver Rivers  Victor Cassano  Other: (name): Do you have now, have you ever had, or has a healthcare provider ever told you that you have any of the following medical conditions?: a. Kidney disease/ End Stage Renal Disease or Dialysis: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  b. History of frostbite, hypothermia or immersion foot: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  c. Liver disease, Cirrhosis or End-Stage Liver Disease Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  d. Heart disease, Arrhythmia or Irregular heartbeat: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  e. HIV+/AIDS: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  f. Emphysema: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  g. Diabetes: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  h. Asthma: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  i. Cancer: Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  j. Hepatitis C Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  k. Tuberculosis Yes No Refused If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  1/9/15 Page 8

Front Door Comprehensive Assessment Domains* l. high blood pressure, hypertension Yes No Refuse  If yes, are you: receiving treatment  received treatment in the past  not receiving treatment  If yes, have you been hospitalized for this in the past year? Yes No Refuse  Programmer –If the individual answers yes to any of questions a-k above and has been hospitalized for it in the past year, make a referral to the Samaritan Clinic for a medical vulnerability assessment.  Have you had a serious brain injury or trauma that required hospitalization or surgery? Yes No Refused  How many times have you been to the emergency room in the past three months? ___________________  How many times have you been hospitalized as an inpatient in the past year? _______________________  How many times have you been hospitalized as an inpatient in the past 3 years? ______________________  Are you currently or have you ever received treatment for mental health issues? Yes No Refused  Have you ever been taken to the hospital against your will for mental health reasons? Yes No Refused  Diagnosis: Medical, Mental Health, Substance Abuse, Mental Retardation, etc. - allow for multiple entries include name, title and date for diagnosis  Is the diagnosis documented by a qualified individual? Y or N  Severity of Each Illness – In SP – “Description of Axis I, II, etc.” but not severity  Current Treatment/Service Providers - Name, Organization and Phone Number (multiple entries)  Previous Treatment Providers – Agency/Hospital, Dates of service – allow multiple entries  Describe how health issues impact housing stability paying rent disruptive behavior hoarding noise visitors Other:  Has health insurance  Y or  N  Current medications list        

Adherence to medication regimen Pick  Almost Always  Sometimes  Never If substance abuse diagnosis, current status and impact on functioning  Actively using and not a problem  Actively using and a problem Reducing use  Abstinent: Date of Sobriety mm/dd/yy Frequency of Use:  Daily  Several Times Per Week  Once a Week  Less than 1X/week Types of substances used: pick list – pick all that apply: Cocaine, Prescription Drugs, Crystal Meth, Amphetamines, Heroin, Marijuana, Alcohol Other: list: Hospitalizations in last 3-5 years - Dates, Reasons, Hospital Names Detox in last 3 years – Number of inpatient detox stays – list of hospitals and clinics but not “detox” Services Needed Motivation to use services: pick Pre-contemplation, Contemplation, Preparation, Action, or Maintenance. Allow room for narrative explanation

Family/Dependent Children            

Domestic violence history Is Juvenile Parent School Attendance/Performance of children Child custody arrangements currently If you have children that are not with you, how many are there? Is there a reunification plan? Yes  or No  Child care arrangements Special Needs Children’s Services Involvement – status, worker name and contact to pre-populate from page 5 Goals Services Needed Motivation to use services: Pick High, Medium or Low

1/9/15 Page 9

Front Door Comprehensive Assessment Domains* Independent Living Skills/ Supports    

Status of ID for all household members Nature of social and familial relationships – identify supports and significant others, also identify negative influences and relationships History of seeking and using help/assistance Goals

Independent Living Skills Checklist 1 - Mostly Independent 2 - Needs Help Sometimes 3 - Needs Help Most of the Time 4 - Always Needs Assistance 1. Paying bills

1-4

2. 3. 4. 5. 6. 7.

Budgeting Maintaining entitlements and other paper work Maintaining a home Preparing/Obtaining meals Travelling Personal Care/hygiene

1-4 1-4 1-4 1-4 1-4 1-4

8. 9. 10. 11. 12. 13.

English Proficiency Awareness of needs and knowing when to seek help Able to access help when needed Managing health/behavioral health needs and services, etc. Taking medications Keeping Appointments

1-4 1-4 1-4 1-4 1-4 1-4

14. Discriminating danger/asserting and protecting self Total Score on Independent Living Skills (Range 14-56) 

1-4

Ability and motivation to improve skills: Pick High, Medium or Low

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Front Door Housing Barriers Screen This form aims to capture some common housing stability barriers facing homeless people and those at risk of homelessness. Much of the information can be found in the intake form. The rest can be gathered directly from the participant. Some information may be unknown or people may refuse to answer. This is to be expected, although it would be preferable to have as much information as possible. The housing barriers screen should be used to develop Housing Plans for each household and for re-assessments for those that receive ongoing assistance. CHECK ALL THAT APPLY. Income Debts/Expenses  No income  Recent increase in monthly expenses  Has income but it’s below 30% of AMI  Monthly obligations exceed monthly income  Recent decrease in income  Poor credit history  Receiving unemployment or other income that is  Currently in bankruptcy time-limited  Debts to the utility company  Sanctioned or timed out on TANF  Paying more than 50% of income for rent Score of 6 Score of 5 Employment Legal Issues  No High School Diploma or GED  Subject to Child Support Enforcement – e.g.,  Unemployed garnish wages  Currently in temporary or seasonal job  On parole  Inconsistent work history – gaps in employment or  On probation frequent changes in jobs  History of incarceration  Lacks adequate transportation  Felony within last 5 years  Restrictions on housing location – e.g., sex offender, DV  Undocumented immigrant Score of 5 Score of 7 Housing History Family Status  Homeless in the last 12 months: ( if currently  Custody of 3 children homeless)  Custody of 4 or more children  Multiple episodes of homelessness  1 or more custodial children < age of 5  Chronically homeless or on long stayer list  Single adult under age 22  One or two legal evictions  Head of household under 25 years old with children  More than 2 evictions or pregnant  Never had own lease  Current or past involvement with foster care system  Lack of rental history of more than 1 year  Unmet child care needs  Barred from public housing for eviction or other  Domestic violence survivor threshold status (crystal meth, etc.)  Has child with special needs  Evicted from other subsidized housing  Children not attending school regularly  History of institutional care – e.g., state hospital, foster care, prison Score of 10 Score of 10 Health/Disability Supports/Independent Living Skills  Chronic physical illness  No or limited support networks  Health crisis, detox or hospitalization in the past year  History of being unable or unwilling to seek help  Ongoing medical needs and no health insurance  Engaged in abusive relationship  One disabling condition such as mental illness, SA  Limited English proficiency  Multiple disabling conditions  Never had driver’s license  Disabling condition has negatively affected housing  Hoards to point of a health or safety risk stability  History of problem visitors in past housing  Not in treatment for ongoing, health, mental health or  No Government Issued ID for any household substance abuse issues member  Does not have 2 landlord references Score of 7 Score of 9 Subtotal Total

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Subtotal

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Level of Need:  High  Medium  Low

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