№ files_lp_3_process_7_088411
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Administrative intake form used to record demographic, financial, health, and program enrollment information for participants in ESG-funded housing assistance programs within HMIS.
Document Type:
Client Intake Form
Program:
ESG Rapid Re-Housing and ESG Prevention
System:
Homeless Management Information System (HMIS)
Funding Sources:
City of Pittsburgh ESG; Allegheny County ESG; State of PA ESG; ESG CV 1; ESG CV 2
Geographic Scope:
Pittsburgh and Allegheny County, Pennsylvania
Target Population:
Adult and Child Program Participants
Data Categories:
Demographics; Household Composition; Domestic Violence; Employment; Income; Non-cash Benefits; Health Insurance; Physical and Mental Health
Includes:
Funding Details; Payment Type; Monthly Income; Disabling Conditions
Signatures Required:
Client Signature; Staff Signature
Assessment Requirement:
Demographic Verification and Data Completion in HMIS
Price: 8 / 10 USD
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Note:
MCI ID
Year:
2021
Region / City:
United States
Topic:
ESG-CV Program, Homelessness Prevention
Document Type:
Guide
Institution:
U.S. Department of Housing and Urban Development (HUD)
Author:
HUD
Target Audience:
ESG program recipients, subrecipients, and HUD reviewers
Effective Period:
2021
Approval Date:
July 19, 2021
Date of Changes:
None
Contextual Description:
A guide for assessing compliance with Rapid Re-housing and Homelessness Prevention requirements under the Emergency Solutions Grant (ESG) program funded by the CARES Act.
Year:
2013
Region / City:
Clinton, Fayette, Highland, Pickaway, Ross Counties
Topic:
Homelessness Prevention and Rapid Re-Housing
Document Type:
Policies and Procedures Manual
Organization / Institution:
Community Action Commission of Fayette County
Author:
Community Action Commission of Fayette County
Target Audience:
Award recipients, sub recipients, and partner agencies
Effective Period:
Ongoing
Approval Date:
April 30, 2013
Revision Date:
August 8, 2016
Year:
Not specified
Region / City:
Not specified
Subject:
Rapid Rehousing (RRH) program documentation and eligibility forms
Document Type:
Internal program guideline
Agency / Institution:
Not specified
Author:
Not specified
Target Audience:
Staff involved in RRH program administration
Period of Validity:
Not specified
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2013-14
Region / City:
Mizoram
Subject:
Health Data Analysis
Document Type:
Report
Organization / Institution:
National Health Systems Resource Centre
Author:
Dr. Sandhya Ahuja
Target Audience:
District level Programme Managers
Approval Date:
June’14
Date of Last Update:
N/A
Year:
2024
Region / City:
Nebraska
Topic:
Homelessness, Point-in-Time Count
Document Type:
Procedure
Organization:
CCFL
Author:
Not specified
Target Audience:
Clarity HMIS System Administrators, Housing Projects, Non-Clarity HMIS Users, Street Outreach Staff
Period of Validity:
January 23, 2024 – February 9, 2024
Approval Date:
Not specified
Modification Date:
Not specified
Year:
2026
Region / City:
Not specified
Subject:
Homelessness, Housing Services
Document Type:
Enrollment Form
Organization:
RHY Program
Author:
Not specified
Target Audience:
Service providers for homeless youth
Duration:
Not specified
Approval Date:
Not specified
Modification Date:
Not specified
Year:
FY24
Program:
CARES Collaborative
Data System:
Homeless Management Information System (HMIS)
Programs Covered:
Supportive Services for Veteran Families (SSVF); Rapid Re-Housing (RRH)
Document Type:
Client Intake Form
Applicable To:
All Clients and Household Members; Adults and Heads of Household
Geographic Scope:
United States
Administering Context:
Homeless Services and Housing Assistance Programs
Required Accompanying Forms:
CCHMIS Client Inclusion Disclosure; Release of Information
Data Elements:
Universal Data Elements; Prior Living Situation; Chronic Homelessness History; Income and Benefits; Health Insurance Coverage
Intended Use:
Project Entry Documentation
Note:
Year
Topic:
Homelessness, Youth Services
Document Type:
Form
Target Audience:
Homeless youth, case managers, service providers
Year:
2021
Region / City:
King County, WA
Topic:
Homelessness management, client intake
Document Type:
Form
Organization / Institution:
HMIS
Author:
Not specified
Target Audience:
Service providers, clients
Period of Validity:
Ongoing
Approval Date:
Not specified
Amendment Date:
Not specified
Year:
2023
Program:
KC VA Services
Region/City:
King County, WA
Document Type:
Status Form
Target Audience:
Individuals receiving VA services, case managers
Date of Issue:
Not specified
Date of Last Revision:
Not specified
Relevant Programs:
HUD VASH, SSVF, GPD
Keywords:
Domestic violence, physical disability, mental health, substance abuse, housing status, income
Context:
A status form used to collect information from individuals applying for VA services, including domestic violence history, health conditions, and housing details.
Year:
2024
Region / City:
United States
Theme:
Emergency shelter intake, client data collection
Document type:
Client intake form
Organization / Institution:
CCHMIS (Coordinated Entry and Homeless Management Information System)
Author:
Not specified
Target Audience:
Homeless shelter staff, service providers
Period of Action:
FY24
Approval Date:
Not specified
Date of Changes:
Not specified
Contextual Description:
A form used for collecting essential data from clients and household members entering emergency shelter programs, including demographic and housing information.
Note:
MCI ID
Year:
2026
Region/County:
United States (specific county to be entered)
Document Type:
Enrollment Form
Organization:
Homeless Management Information System (HMIS)
Target Audience:
Street Outreach Program Staff and Case Managers
Purpose:
Record client information, housing history, disabling conditions, and domestic violence status
Program Enrollment Date:
To be entered per client
Head of Household:
To be entered per client
Household Members:
To be entered per client
Prior Living Situation:
To be entered per client
Length of Homelessness:
To be entered per client
Disabling Conditions:
To be entered per client
Domestic Violence Experience:
To be entered per client
Data Collected:
Individual client information for case management and program tracking
Fiscal Year:
FY24
Program:
CARES Collaborative HMIS
Thematic Area:
Homelessness services and emergency shelter intake
Document Type:
Client intake form
System:
Homeless Management Information System (HMIS)
Program Component:
Emergency Shelter
Country:
United States
Responsible Program:
CARES Collaborative
Target Population:
Individuals and households entering emergency shelter programs
Data Categories:
Universal data elements; Program specific data elements
Key Data Collected:
Personal identification, demographic information, prior living situation, homelessness history, income sources, non-cash benefits, health insurance coverage, disability and health conditions, domestic violence status, language assistance needs, last permanent address
Client Information Fields:
Name, Social Security Number, gender identity, race and ethnicity, date of birth, veteran status
Housing Status Fields:
Prior living situation, duration of stay, date homelessness began, frequency and duration of homelessness
Economic Information Fields:
Earned and unearned income sources, public benefits, retirement income, unemployment benefits
Health and Social Conditions Fields:
Physical disability, developmental disability, chronic health condition, HIV/AIDS status, mental health disorder, substance use disorder
Safety Information:
Domestic violence survivor status and recency
Administrative Instructions:
One form completed per client or household member at project entry
Required Responses:
Starred questions must be asked of each client, with response options for unknown or declined answers
Year:
2025
Organization Type:
Nonprofit Agency
Funding Program:
Emergency Solutions Grant (ESG)
Document Type:
Grant Application Form
Jurisdiction:
City of Canton, Stark County, Ohio, USA
Contact Person:
Specified within document
Required Attachments:
Organizational chart, position descriptions, audit report, financial statement, operating budget, IRS 501(c)(3) designation, Articles of Incorporation, bylaws, Certificate of Good Standing, board members list, recent board minutes, conflict of interest policy, facility accessibility statement, program goals summary, participant termination policy, proof of tax compliance, employment practices certification
Scope:
Homelessness prevention, rapid re-housing, emergency shelter, street outreach, HMIS activities
Funding Requirements:
1:1 cash match for all activities
Submission Certification:
Signed by CEO/Executive Director
Year:
2026
Region / City:
Not specified
Theme:
Housing, Social Services
Document Type:
Client Intake Form
Organization / Institution:
Not specified
Author:
Not specified
Target Audience:
Clients of housing services
Effective Period:
Not specified
Approval Date:
Not specified
Date of Changes:
Not specified
Year:
2014
Region:
Meghalaya, India
Document Type:
Health Management Information Report
Subject:
Maternal and Child Health, Family Planning
Data Period:
April 2014 – September 2014
Target Population:
Pregnant women and newborns in high priority districts
Districts Covered:
West Khasi Hills, South Garo Hills, West Garo Hills, East Jantia Hills, West Jantia Hills
Indicators Included:
Population projections, estimated pregnancies, ANC registration, deliveries, live births, postnatal care, family planning methods
Institutions Involved:
Public and private health facilities