VHC Universal Intake

VALLEY HOMELESS CONNECTION UNIVERSAL INTAKE

Please answer all questions as completely as possible.
Completing this form will allow us to connect you with resources that might be able to help, including emergency shelter and permanent housing programs designed for folks experiencing homelessness.

Please be sure to click the "Submit" button at the end in order for your information to get to us.
HEAD OF HOUSEHOLD PERSONAL INFORMATION
FULL NAME (Please ensure spelled accurately)*

First NameMiddle NameLast Name
HAVE YOU SERVED IN THE MILITARY?*

YesNo
DATE OF BIRTH*

MonthDayYear
SOCIAL SECURITY *
(Do not enter hyphens--PLEASE double check)
How did you hear about us?
Agency, person or other.
CURRENT CLIENT PHONE OR MSG #*
Please double check number before continuing.
EMAIL ADDRESS
example@example.com
If you don't have a phone number, please tell us where we can find you to help you?
EMERGENCY CONTACT NAME
Will only be used in case of illness or other emergency.
EMERGENCY CONTACT RELATIONSHIP
Will only be used in case of illness or other emergency.
EMERGENCY CONTACT PHONE
Please enter a valid phone number.
RACE & ETHNICITY*
GENDER *
Do you need translation assistance?*

DIVERSION
Is there someone (a friend, family member, etc) that you could stay with for the next three days?*

YesNo
Do you have resources to obtain housing on your own? (Savings, earned income, etc)*

YesNo
Could you safely return to the place you most recently resided?*

YesNo

Are you covered by any type of medical insurance?*

MedicareMedicaidEmployer providedOther
Please list insurance carrier if known

Do you have a disabling condition?*

YesNo
If yes, please choose all that applies to you:*

Physical disabilityMental Health DisorderHIV/AIDSSubstance Use DisorderDevelopmental disability
If yes, who can provide written documentation of this condition?

Are you a Survivor of Domestic Violence?*

YesNoPrefer not to answer
If yes, are you currently fleeing?

YesNoPrefer not to answer
If yes for Survivor of Domestic Violence, when did your experience occur?
What is your sexual orientation?

NOTE: Is there anything else you would like us to know?

ARE YOU COMPLETING THIS FOR YOURSELF OR A CLIENT?

I am completing this for myself.I am completing this on behalf of somebody else.

VERBAL HCIS RELEASE

READ TO CLIENT AND ALLOW RESPONSE

We would like your permission to share your information with other community agencies, who have agreed to keep it confidential. Your information will be entered into a secure database, and sharing information makes it easier to coordinate services and track how well we are meeting your needs. In rare cases, we would also share your information in instances of mandatory reporting or to provide better services.

If you have questions or concerns, would like a copy of the full privacy notice, or would like to see the information being shared, please let me know.
Do I have your permission to share your personal information with other homeless system service agencies and partners? (If the client says no, they will be entered into HMIS, but the information will not be shared with other providers. If the client requests that information is not entered into the database, the provider should honor that request.)
CLIENT AGREES TO SHARING OF INFORMATION WITH OTHER AGENCIES

YesNo

Homeward Community Information System (HCIS)

Authorization for Release of Information

When you request or receive services from this agency, we collect information about you and/or your household that is entered into a computerized database called HCIS. This agency and other area agencies that provide services to people who are homeless or at risk of homelessness use this information to identify services and resources that may be of interest to you. This information is also used to improve service coordination and to produce reports.

This form is provided for you to give your permission for your information that is entered in HCIS to be shared with Partner Agencies. Below is a description of the information that is being collected, how it is shared (with your permission), the purpose for sharing, and how your information is protected.

What information is collected?

Depending on your situation, you may be asked for some or all of the following:

 Basic identifying information (examples: name, SSN, date of birth);

 Demographic information (examples: gender, race, ethnicity, veteran status, disability information, household relationships);

 Housing information (examples: prior housing situation, homeless status, reasons for homelessness);

 Income & Benefits information (examples: sources and amounts of household income, enrollment in benefit programs, employment information); and

 Health-related information (examples: diagnoses, mental health conditions, substance abuse history, medications). Please note: Specific health-related information in HCIS is never shared among Partner Agencies.

How is information protected?

 Partner Agencies must abide by relevant state or federal laws protecting client data;

 HCIS Policies and Procedures establish additional protections for client data including requirements for hardware, software, security, confidentiality, and training;

 Data is entered into HCIS via a secure and encrypted internet connection; and

 HCIS data is encrypted and stored in a secured facility.

Why is information collected and how is it used or disclosed?

 To better assess your needs and the needs of others in the community;

 To make it easier for clients to receive services from several agencies;

 To track whether your needs and the needs of others are being met;

 To improve the quality of care and service for people who are homeless or at risk of homelessness;

 To better provide or coordinate services among local service providers;

 To perform functions related to payment or reimbursement of services;

 To carry out administrative functions (such as legal, audits, personnel, oversight, and management functions); and

 To conduct research on issues and programs related to homelessness (either on de-identified (anonymous) data or with parties who have signed an agreement to protect your privacy).

Partner Agencies offer a variety of services of interest to our clients. Connecting these agencies through HCIS makes referrals easier and decreases duplicative intakes through many programs. By sharing your information with Partner Agencies, you will help them:

 Identify other services or programs you may be eligible for;

 More accurately count the number of homeless persons, the services available, and what other services are needed; and

 Show the people who fund homeless programs that the services are needed and help the agencies to obtain other funding for programs that serve homeless persons.

HCIS Release of Information (revised 12/06/17)

More rarely, disclosure of HCIS data may also be permitted:

 As required by law, including in response to a lawful court order, court-ordered warrant, subpoena, or summons issued by a judicial officer,

 To avert a serious threat to health or safety

 To report abuse, neglect, or domestic violence to a governmental authority.

How is information shared?

Once you sign the Release of Information or provide a verbal release, your record is made available to Partner Agencies. If you choose not to sign the Release of Information or provide verbal consent to share your information, only limited information will be made available to Partner Agencies in HCIS to ensure your record is not duplicated. However, your specific interaction with this Agency will not be available to other Partner Agencies.

Other agencies that do not use HCIS may access your information to assist with the coordination of services if they sign an agreement to protect your privacy. At any time, you may revoke your permission to share your information and this will prevent further sharing with Partner Agencies. Specific health-related information (e.g., diagnoses, mental health conditions, substance abuse history, medications) in HCIS is never shared among Partner Agencies.

This policy may be amended at any time and amendments may affect information obtained before the date of the change.

You may obtain a copy of the information we have about you (unless we are unable to provide one due to legal proceedings), as well as request corrections be made to your information.

If you have questions or complaints regarding the privacy or security of your information in HCIS, you may write directly to:

Homeward

9211 Forest Hill Ave., Suite 200

Richmond, VA 23235

email: hcis@homewardva.org

Consent

Please review the statement below and provide your signature if you agree. A current list of HCIS Partner Agencies and the requirements for participation is available by request from Homeward or at http://homewardva.org/about/grcoc/partners.
Please sign below if you have read the above release and agree to the HCIS' Release of Information

Clear
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VALLEY HOMELESS CONNECTION UNIVERSAL INTAKE

HEAD OF HOUSEHOLD PERSONAL INFORMATION

DIVERSION

HOMELESS STATUS

FINANCIAL & BENEFITS INFORMATION

Other Household members