Intake Form - Singles printable pdf download

Salinas/Monterey, San Beniot Drop-in Center Intake Form – Singles

HMIS #: ______

___

Date_______________

Homeless Management Information System

DROP-IN CENTER RELEASE OF INFORMATION AUTHORIZATION

is a Partner Agency in the Homeless Management Information System, a shared homeless and at-risk housing

database system administered by The Salinas/Monterey, San Benito Coalition of Homeless Services Providers and Community

Technology Alliance. HMIS operates over the Internet and uses many security protections to ensure confidentiality. Participation in the

HMIS program is important to our community’s ability to provide you with the best services and housing possible. As you receive

services, information will be collected about you, the services provided to you, and the outcomes these services help you to achieve.

- Your name and other identifying information will not be shared with any agency not participating in the system. (Unless required to

do so by law.)

- Your name, gender, social security number and date of birth may be shared with Partner Agencies for identification purposes even if

you elect not to share other relevant information.

- A list of Partner Agencies is available on request.

- Authorizing your information to be entered into the HMIS is voluntary.

- Refusing to do so will not limit your access to shelter or services.

Please initial one of the following levels of consent:

_____ (1) I give authorization for my basic and relevant information to be entered into the HMIS and shared between Partner Agencies. I understand

that I have the right to receive a copy of all information shared between the Partner Agencies.

_____ (2) I give authorization for my basic and relevant information to be entered into the HMIS, but not shared between Partner Agencies.

I understand that I may cancel this authorization at any time by written request. I understand that this release is valid for three years from the date of my

signature below.

Print Name of Client or Guardian

Signature of Client or Guardian

Date

1. First Name

Middle _______________ Last ____________________________

2. Social Security No.

3. Birth Date

 Male

 Female

 Transgender

If Transgender:  Female to Male  Male to Female

4. Gender:

 Yes

 No

5. Are you of Hispanic or Latino origin?

6a. What is your Primary race?

 American Indian/Alaskan Native

 Asian

 Black/African-American

 Native Hawaiian/Pacific Islander

 White

 Don’t Know

 Refused

6b. What is your Secondary race?

(optional, answer if you are of mixed race)

 American Indian/Alaskan Native

 Asian

 Black/African-American

 Native Hawaiian/Pacific Islander

 White

 Don’t Know

 Refused

7. Housing Status:  Literally Homeless

 Housed at Imminent Risk of Losing Housing (High Risk)

 Housed and at Risk of Losing Housing

 Stably Housed

 Don’t Know/Refused

8. Phone/Message Number

9. Email Address

 Yes

 No

10. Do you require special accommodations to access the program services?

11. Current/Last Permanent Address (where you resided for 90 days or more, non-homeless housing)

Address

When did you leave this address?

City

State

Zip

(month and year)

12. Please check what best describes your living situation last night:



 Emergency Shelter

 Transitional Housing

Rental w/housing subsidy

(for homeless)



 Psychiatric Facility

Rental by client,

VASH

Substance Abuse Treatment Facility

Housing Subsidy



 Safe Haven

 Hospital

Rental w/other subsidy

 Hotel or Motel



 Jail or Prison

Permanent Housing

(

for formerly

 With Family

 With Friend

 Car or Other Vehicle

homeless)

 Foster Care Home

 Owned by Client w/Subsidy

 Transportation Site

 Hospital

 Other



Outside/Abandoned Building/ Non-



Rental House/Apartment

(No Subsidy)

 Don’t Know  Refused

Housing (street, park, etc.)

Salinas/Monterey, San Benito Drop In Form Page 1 of 2

Intake Form - Singles

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