Supportive Services Form For Hmis

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New Hampshire Continua of Care – Emergency Solutions Grants (ESG)/
Homelessness Prevention (HP) and Rapid Rehousing (RRH) Programs
Supportive Services Form for HMIS
(Required for each client receiving services)
Additional Supportive Services Data
Prevention
Homeless
(
)
(
)
at risk, but not homeless
needs RRH/Rapid Rehousing
Record the Start and End dates of the services provided; where applicable, include the dollar amount. Collect and
enter this information when services are provided as a one-time transaction and at least once every three months for
programs that provide on-going services for consecutive months. Ensure that the Service dates do not start prior to the
Client’s Entry Date into HMIS; the Entry Start Date should always coincide with the start of financial assistance.
This data will be input to HMIS. If you need additional forms in order to add services for a client after initial intake, they
can be found on the HMIS website at
When adding Services information into ServicePoint, it is important to use the correct Funding Source based on the
program type (HPRP has been retired):
Prevention= NH ESG Homeless Prevention
RRH=NH ESG Rapid Re-housing (RRH)
Project Name: _____________________________________________Date:__________________
Interviewer Name: ___________________________________________
Client Name: _______________________________________________ServicePoint ID #: _____________
Start Date
End Date
Service
Amount
(MM/DD/YYYY)
(MM/DD/YYYY)
Rental payment (includes rental arrears)
$
___/___/______
___/___/______
Rental deposit (security deposit)
$
___/___/______
___/___/______
Housing search (includes rental application
$
and costs for housing inspection)
___/___/______
___/___/______
Moving expense
$
___/___/______
___/___/______
Utility deposit
$
___/___/______
___/___/______
Utility service payment
$
___/___/______
___/___/______
Credit counseling
$
___/___/______
___/___/______
Case/care management
$
___/___/______
___/___/______
Transportation (only for ESG prevention)
$
___/___/______
___/___/______
Total amount
$
When a client exits, be sure to do the following in ServicePoint from the Service Transaction Tab:
update the End Date; especially watch for Services that have been added quarterly
change the Need Status to “Closed”
edit the Outcome of the need related to the service at this time
10/2014
ESG HP & RRH Additional Supportive Services Form
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New Hampshire Homeless Management Information System (NH-HMIS)

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