3-County Coc Hud Intake/exit Form (Universal Elements Only) Form Page 2
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2Housing Information
Questions in this box are only required of adults (18 and over) and unaccompanied youth (17 and under)
Where did you stay last night (prior living situation on night before program entry)?
_____ Emergency shelter
_____ Rental by Client no subsidy
_____ Safe Haven
_____ Transitional housing for homeless
_____ Owned by Client no subsidy
_____ Rental by client w VASH
_____ Permanent housing for homeless
_____ Owned by client w subsidy
_____ Rental by client w GDP TIP
_____ Staying / living w family
_____ Staying / living w friend
_____ Rental by client w other subsidy
_____ Psychiatric Hospital / facilities
_____ Substance Abuse facility
_____ Hotel / Motel no ES subsidy
_____ Hospital (non-psychiatric)
_____ Foster care home / group home
_____ Don't know
_____ Jail, Prison or detention facility
_____ Place not for habitation
_____ Refused
_____ Long-term Care/ Nursing Home
_____ Residential Project/ Halfway House w no homeless criteria
_____ Other:_____________________
Length of stay at location selected above
____ 1 day or less
____ 2 days to 1 week
____ More than 1 week but less than 1 month
____ 1 to 3 months
____ More than 3 months but less than 1 year
____ 1 year or longer
____ Don’t Know
____ Refused
Current Location:
MA - 507 *
*This must be entered into the HMIS. It is a code for our
CoC.
Exit information
Exit Date ____/____/________ mm/dd/yyyy
What is the client’s destination upon exit?
_____Deceased
_____ Owned by Client no subsidy
_____ Emergency shelter
_____ Owned by client w subsidy
_____ Rental by Client no subsidy
_____ Safe Haven
_____ Rental by client w GDP TIP
_____ Transitional housing for homeless
_____ Rental by client w VASH
_____ Permanent housing for homeless
_____ Substance Abuse/ Detox facility
_____ Rental by client w other subsidy
_____ Staying / living w family temp.
_____ Staying / living w family perm.
_____ Hotel / Motel no ES subsidy
_____ Staying / living w friend temp
_____ Staying / living w family temp.
_____ Place not for habitation
_____ Psychiatric Hospital / facilities
_____ Foster care home / group home
_____ Don't know
_____ Hospital (non-psychiatric)
_____ Jail, Prison or detention facility
_____ Refused
_____ Long-term Care/ Nursing Home
_____ Residential Project/ Halfway House w no homeless criteria
_____ Other:_____________________
_____ Moved from one HOPWA funded project to HOPWA PH
No exit interview completed
_____
_____Moved from one HOPWA funded project to HOPWA TH
Notes
Last Updated: 10/26/2015
This form reflects the 2014 HUD HMIS Data Standards, which HUD updated 9/2015
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