"Ce Basic Intake Form" - Georgia (United States)

Ce Basic Intake Form is a legal document that was released by the Georgia Department of Community Affairs - a government authority operating within Georgia (United States).

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CE Basic Intake Form
1
“*” Required Fields
Client Demographics
First Name:*
Last Name:*
Middle Name:
Suffix:
HoH: *
Social Security Number
Name Data Quality:*
:*
Birthdate
:*
Full DOB Reported
Full Name Reported
Full SSN Reported
Partial, or Street Name
Approximate or Partial SSN
Approximate or Partial DOB
Client Doesn’t Know
Client Doesn’t Know
Client Doesn’t Know
Client Refused
Client Refused
Client Refused
Data Not Collected
Data Not Collected
Data Not Collected
Race:* (Select all that apply)
Ethnicity:*
Gender:*
American Indian or Alaska Native
Hispanic/Latino
Male
Female
Asian
Non-Hispanic/Latino
Transgender Female to Male
Black or African American
Client Doesn’t Know
Transgender Male to Female
Native Hawaiian or Other Pacific Islander
Client Refused
Gender Non-Conforming
(i.e. not
exclusively male or female)
White
Data Not Collected
Client Doesn’t Know
Client Doesn’t Know
Client Refused
Client Refused
Relationship to Head of Household:*
Data Not Collected
Data Not Collected
Self
Spouse
If Female, Pregnancy Status:*
Daughter
Veteran Status:* (18 & over)
Yes Due Date: ___________
Son
No
Yes
No
Dependent Child
Client Doesn’t Know
Client Doesn’t Know
Other Family Member
Client Refused
Client Refused
Other Non-Family Member
Data Not Collected
Data Not Collected
Contact Information:*
Client’s Personal Phone Number
Agency Number
Best Contact Phone Number:
Family/Friend Phone Number
No Contact Phone Number Available
2
CE Basic Project Enrollment
Project Start Date:*
Case Manager:
3
Entry Assessment
Disabling Condition:*
Client Location (The CoC the client is being served in):*
(GA-500) Atlanta
(GA-501) Balance of State
Yes
(GA-502) Fulton County
(GA-503) Athens/Clarke County
No
(GA-504) Augusta
(GA-505) Columbus/Russell County
Client Doesn’t Know
(GA-506) Marietta/Cobb
(GA-507) Savannah/Chatham County
Client Refused
(GA-508) DeKalb County
Data Not Collected
CE Basic Intake Form
1
“*” Required Fields
Client Demographics
First Name:*
Last Name:*
Middle Name:
Suffix:
HoH: *
Social Security Number
Name Data Quality:*
:*
Birthdate
:*
Full DOB Reported
Full Name Reported
Full SSN Reported
Partial, or Street Name
Approximate or Partial SSN
Approximate or Partial DOB
Client Doesn’t Know
Client Doesn’t Know
Client Doesn’t Know
Client Refused
Client Refused
Client Refused
Data Not Collected
Data Not Collected
Data Not Collected
Race:* (Select all that apply)
Ethnicity:*
Gender:*
American Indian or Alaska Native
Hispanic/Latino
Male
Female
Asian
Non-Hispanic/Latino
Transgender Female to Male
Black or African American
Client Doesn’t Know
Transgender Male to Female
Native Hawaiian or Other Pacific Islander
Client Refused
Gender Non-Conforming
(i.e. not
exclusively male or female)
White
Data Not Collected
Client Doesn’t Know
Client Doesn’t Know
Client Refused
Client Refused
Relationship to Head of Household:*
Data Not Collected
Data Not Collected
Self
Spouse
If Female, Pregnancy Status:*
Daughter
Veteran Status:* (18 & over)
Yes Due Date: ___________
Son
No
Yes
No
Dependent Child
Client Doesn’t Know
Client Doesn’t Know
Other Family Member
Client Refused
Client Refused
Other Non-Family Member
Data Not Collected
Data Not Collected
Contact Information:*
Client’s Personal Phone Number
Agency Number
Best Contact Phone Number:
Family/Friend Phone Number
No Contact Phone Number Available
2
CE Basic Project Enrollment
Project Start Date:*
Case Manager:
3
Entry Assessment
Disabling Condition:*
Client Location (The CoC the client is being served in):*
(GA-500) Atlanta
(GA-501) Balance of State
Yes
(GA-502) Fulton County
(GA-503) Athens/Clarke County
No
(GA-504) Augusta
(GA-505) Columbus/Russell County
Client Doesn’t Know
(GA-506) Marietta/Cobb
(GA-507) Savannah/Chatham County
Client Refused
(GA-508) DeKalb County
Data Not Collected
4
Prior Living Situation*
From the options below, choose the ‘type of situation’ that most closely matches where the client was living on the night before
the enrollment. Choose ONLY ONE! Adult members of the same household may have different prior living situations.
Institutional Situation
Homeless Situation
Transitional & Permanent Housing Situation
Place not meant for habitation
Foster care home or foster care group home
Residential or halfway house w no homeless criteria
Emergency shelter, including hotel or mo-
Hospital or other residential non-psychiatric
Hotel/motel paid for w/o emergency shelter voucher
tel paid for with emergency shelter vouch-
medical facility.
Transitional Housing for Homeless Persons
er, or RHY-funded Host Home shelter.
(including homeless youth)
Jail, prison, or juvenile detention facility
Safe Haven
Long-term care facility or nursing home
Host Home (non-crisis)
Psychiatric Hospital or Other Psychiatric
Staying or living in a friend’s room, apartment or house
Facility
Staying or living in a family member’s room, apart-
ment or house
Substance Abuse Treatment Facility or Detox
Center
Rental by client, with GPD TIP subsidy
Rental by client, with VASH housing subsidy
Permanent housing (other than RRH) for formerly
4.1 | Stay less than 90 days?:*
homeless persons
 No (ask 4.4)  Yes (ask 4.3)
Rental by client, with RRH or equivalent subsidy
Rental by client, with HCV voucher (tenant/project
4.2 | Stay less than 7 days?:*
based)
 No (ask 4.4)  Yes (ask 4.3)
Rental by client in a public housing unit
Rental by client, with no ongoing housing subsidy
4.3 | On the night before did you stay
Rental by client, with other ongoing housing subsidy
on the streets, ES, or SH?:*
Owned by client, with ongoing housing subsidy
 Yes (ask 4.4)
Owned by client, no ongoing housing subsidy
 No
Proceed to section 6 (next page)
Client Doesn’t Know
Client Refused
Data Not Collected
4.4 | Length of stay in the prior living situation
 1 night or less
 2 to 6 nights
 1 week or more; but less than 1 month
 1 month or more, but less than 90 days
 90 days or more, but less than 1 year
 One year or longer
 Client Doesn’t Know
 Client Refused
 Data Not Collected
5
History of Homelessness
Record the actual or approximate date this homeless situation began (i.e.
Approximate date homelessness started:
the beginning of the continuous period of homelessness on the streets, in
ES, in SH, or moving back and forth between those places)
Total number of months homeless on the street, in ES, or SH in the
(Regardless of where they stayed last night)
past three years
Number of times the client has been on the streets, in ES, or
SH in the past three years including today
 One month (this time is the first month)
 3
2
 2 times
 4
 5
 6
 7
 9
1 time
8
 4 or more times
 10
 11
 12
 More than 12 months
3 times
Client doesn’t know  Client refused
 Client Doesn’t Know
 Client Refused
 Data Not Collected
Data not collected
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