HomeMy WebLinkAbout2013-1015 Documents Submitted at Meeting
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PROJECTED OUTCOMES: ASHLAND HELP CENTER PROPOSAL 14 NW'd
Submitted by AC
CESS & OHRA October 15, 2013 Projected outcomes over 2-year term of grant Number of light-touch services delivered 1800
Number of clients helped with long-term collaboration 120
Number of homeless clients housed 40
Number of families successfully avoiding homelessness 30
Number of clients achieving stable income or jobs 24
Number of active community partners 12
Donations $20,000.00
Client satisfaction measured by survey 80%
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Helping People Help Themxehex n
Homeless Prbiect Outreach 8 Assessment
FirsULast Name Date:
Telephone First Time: Return:
STAFF: Check Services III,
/ Referrals APPLICANT:
Signed Up Referral In each category, Circle All That Apply. Your responses will allow us to
Made determine how we may be able to assisti......
I'IIIII' 'II{I{i{a
EMPLOYMENT STATUS None Part Time Stable Full Time Stable
d{1{h 'IIIIIIII
n Shut Off I,IIIIIIIIII Final Notice 1111 (1Ihl.
r_ ENERGY STATUS 48 hour hanging Current
noticelI111111I' Past Due ~IIIIII(II
u..10 t of food Food situation is good
FOOD No Food'. Rft en
~IIIIh. do
't~
No Transport a~Illtiolhn 1111finreliable Car Have Vehicle
TRANSPORTATION No License ~l(II Bus / Walk / Have License
~Ij~~~III IINo{ insure Bicycle Have Insurance
low 111114
y I 1[111) I 11111 1. Certified
I{Ihh• Have childcare
CHILD CARE Need childcare in Stable with Backup
(III. AIIIIIIIIIIIIII. Can't afford Not Needed
I 411 II1II'~ ~'gl'.(hzih~.
~~~~~~~JIIIIIIIIIIIII~,. I(I({Id(~~~IP~ lIA19F Wages
FAMIL''Y INCOME oSUn6ployment
ocial Security Other Source
I(I{{ Owe orilde
Bills Current
DEBT OBLIGATIONS and fines No Debt
~~~~~Ilhbts Some Bills Late
~l{IIIiIIIIIIIIIIIII ~~1.. ,llhl.
112111 lift" Limited famil, Good su ort from
NF4 No family, friends, y PP
SUPPORT SYSTEM n friends, or church, family, friends or
11, 111111{, or church etc etc. church etc
IIII~~) I1IHEALTH Poor Fair Good
III~I{I. I{{{{h,
Oher Information/R s¢ III~~~~I II (I
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HMIS Data: UNIVERSAL INTAKE FORM rvsd 7-8-13 10/15/2013
Outreach & Drop-in Intake Form
FOR TEXT FIELDS, USE BLOCK LETTERS. OTHERWISE, MARK APPROPRIATE BOXES WITH AN "X"
Fill out separate form for each household member and clip together.
PROGRAM ENTRY DATE (e.g., 05/24/2010) [All clients]
Month Day Year
Client Client
does refused
CURRENT NAME (first, middle, last name, suffix (e.g ' Jr, Sr, III)) [All clients ( not to
Ali, yy NIA know provide
First name
.l
nalme dl (I~ (I il'1I) I❑ El ❑
VIII II ~ ~ ❑ ❑
Last name IT,
d . )h,
Suffix '111111 El
.
SOCIAL SECURITY NUMBER [All clients] DATE OFIBIR
li Illlil) II Il
BIRTH (e.g., 10/23/1978) [All clients]
Month[ ~1)D'a'y Year
III Iilllllllllllllii.,.
SOCIAL SECURITY NUMBER AND !T!Y4PEI[All clients] ~~III DATE OF BIRTH AN(DIITYPE [All clients]
❑ Full SSN reported ll~l~l~llflllil)IIIII~II~! ll I lil IIIlFull date of birth reported
uo
❑ PartlalxSSN reported Approximate or partial date,of birth reported M
dill iP
F] Client does not know or does not havASN aullj) `Client does not know
~u w n n - if
Che` t rre used to rovide _
❑ .,.~p.~~~ 7 Y m-. ❑ Client refused to,provlde ~
I ~
ull
RACE More thi3ntl'onne~race is permlitteld! [Allclients]
( I~~' I
JUllll) ulw1U11111'It,. 9P1Yu
❑ American Indian or Alaskan Natweh ❑ White
❑ , Asian ❑ Client does not know
❑ Black l6or African American I~II(il I ( , ❑ Client refused to provide
'I Illb
~ttl - -
❑ NatiJe /'Hawaiian or"Other Pacific Islander "
ETHNICITY[All ccli~~ts]
Non-His I ~I111h`) ❑
anic % ~eFon atino ! Client does not know
❑ Hispanic /Latino ❑ Client refused to provide
GENDER [All clients]
❑ Female ❑ Other
Male Client does not know
❑ Transgendered male to female ❑ Client refused to provide
❑ Tra`n59gndered female to male
3
HMIS Data: UNIVERSAL INTAKE FORM rvsd 7-8-13 10/15/2013 °
VETERAN STATUS [All adults] DISABLING CONDITION [All clients]
❑ No ❑ No
❑ Yes ❑ Yes
❑ Client does not know ❑ Client does not know
❑ Client refused to provide ❑ Client refused to provide
RESIDENCE PRIOR TO PROGRAM ENTRY [All adults and unaccompanied youth]
Place not meant for habitation (e.g. a vehicle, an
~
❑ Emergency shelter, including hotel or motel paid El abandoned building, bus~~/train/subway
for with emergency shelter voucher station/airport or'snyw~here outside)
- All flit,
❑ Transitional housing for homeless persons ❑ Other: (Describe)
(including homeless youth)
Permanent housing for formerly homeless persons oil, ,Ilr
❑ (such as SHP, S+C, or SRO Mod Rehab) E] Siii Haven
i~I (~I~ilr
❑ Psychiatric hospital or other psychiatric facility ❑ Rental by client, with VASH housing subsidy
El Substance abuse treatment facility or detox center .11 IRental by client., with other (non-VATS ft ousing
1~subsidy
❑ Hospital (non psychiatric) ❑ Owned by client, with ongoing housing subsidy
❑ Jail, prison, or juvenile detention facility ❑ Rentallby~client, no ongoing housing subsidy
fit IlL
Staying or living in a family member's room,
❑ II II III
apartment, or house Owned by client, no ongoing housing subsidy
.q ,
Staying or living in a friend's room, apartment,
house ro~ rlle~) I rl~~~~~)
❑ I El CI (eiltltloes not know
- - ,,tAlll~~lllpo, ~~I~) ~IIIII'' "IIllllllllla
Hotel or motel paid for without emergency shelter ~l
❑ voucher II Client refused to provide 11 - dr11 111'~I ~IiI _
❑ Foster care homelorllf fos
ister care group1~}}h~11o,1me
"if 111h
.1111 ( h, II~~IIIIIIIII~Ihul~.. I O ~I.
LENGTH OF STAY IN PREVIOUSIPLACE (All adults,and accompanied youth]
❑ One week(pt11,essl I~~~I~II~IIIII111 dlll)1111) ii, ~Ir One year or longer
nuu a uuu Ih.
More than one week, but less than one month Client does not know
❑ ~hOng1to three months ~I)I'IIII~I4 ~I~I~IIIIII ❑ Client refused to provide
❑ More than 3 months, but less than one year
ZIP CODE OFI'IIA;ST PERMANENT ADDRESS AND TYPE [All adults and unaccompanied youth]
Zip code ~~"I~~; (III ❑ Full or partial zip code reported
I 111
❑ Client does not know
IIIII~IIII I~fl ~I ❑ Client refused to provide
t
HOUSING STATUS [All clients]
❑ Literally homeless ❑ Stably housed
❑ Imminently losing their housing ❑ Client does not know
❑ Unstably housed and at-risk of losing housing ❑ Client refused to provide
4
HMIS Data: UNIVERSAL INTAKE FORM rvsd 7-8-13 10/15/2013