New Intake Form

Welcome to Evergreen!

Completion of this form is voluntary. It is your right to decline to provide any information you do not wish to disclose. Keep in mind that the more information you provide, the better we can connect you to the right services. By completing and signing this application, you are acknowledging that the information you’ve provided is true and correct to the best of your knowledge. Thank you for taking the time to complete this form and trusting us to serve you!
Today's Date *

Month Day Year
Date
Are you currently experiencing any of the following immediate safety concerns? *

No shelter during dangerous weather conditions In immediate danger from another person Other physical danger Need immediate medical attention Suicidal ideation or attempt Other mental health crisis No immediate safety concern
If yes, please tell us about the situation
Minnesota's HMIS Data Privacy Notice

We collect personal information about the people we serve in a computer system called Minnesota’s HMIS (Homeless Management Information System). Many social service agencies use this computer system, including street outreach, shelters, and housing programs.
Why do we collect this information?
• To help keep this program and others like it going. We are required to use HMIS.
• So we know how many people we serve and the types of people we serve at our agency and in the state.
• So we all understand what people need and can plan services to meet these needs.

Who can see information that is in Minnesota’s HMIS?
• People who work for this agency will use it to help provide services to you or your family.
• Other agencies like this agency that provide services and have received permission from you to see your information. The agencies that participate in Minnesota’s HMIS may change from time to time. A copy of the current list of participating agencies is available upon request.
• Auditors or funders who have legal rights to review the work of this agency, such as the U.S. Department of Housing and Urban Development and other state or local government entities.
• Organizations that run, administer, and work on the system, such as the Institute for Community Alliances or Local System Administrators. When these organizations work on the system, they may see information about you.
• People using HMIS information to do research and write reports, including, but not limited to, the Minnesota Department of Human Services (DHS). Your personally identifiable information will never appear in research reports.
• The law says we have to report physical or sexual abuse of children and vulnerable adults. If we think there is abuse or neglect in your household, we will report it to Child or Adult Protection.
• We may release your information to protect the health or safety of you or others as required by law.
• Others as required by law, including officials with a valid subpoena, warrant, or court order.

We will not release your information for any other use unless you permit us in writing.

How is your privacy protected?
• All users of data must sign an agreement to protect your privacy and comply with state and federal laws and policies before seeing any information.
• The computer program used for this purpose has industry standard security protocols and is updated regularly to meet these security requirements.

What are your rights?
• If you do not want your name, social security number, or date of birth entered in HMIS, tell the intake worker. This agency will not refuse to help you for denying this. However, federal and state regulations may require limited data collection for funding purposes.
• You have the right to request a copy of the Minnesota’s HMIS information about you.
• You have the right to correct mistakes in HMIS information about you.
• If you think this agency or Minnesota’s HMIS violated your privacy rights, you have the right to complain or appeal. Ask a staff person for a complaint and appeal form.
Your personal information will be collected in Minnesota’s HMIS and, with your consent, shared with other service providers/homeless agencies. If you do not give permission for this agency to share your information, no other agency in the network will have access to it.

Why share your information?
• Sharing reduces the amount of time you have to spend answering basic questions about your situation.
• Sharing allows agencies to focus on meeting your unique needs more quickly.
• Sharing makes it easier for multiple agencies to coordinate housing and services for you and your family.

What information might be shared?
• Family/Household information
• Name, birthdate, Social Security Number
• Gender, race, ethnicity
• Reasons for seeking services
• Living situation and housing history
• Services you receive
• If you are homeless or not
• Your income and income sources
• Public benefits you receive
• History of domestic violence
• Educational background
• Employment information
• Military history
• Health information, including physical health, HIV, behavioral health
Please check (✓) a box: *

SHARE: I consent to have the information collected about me shared through Minnesota’s HMIS with other partner agencies in order to improve services to me and the services offered to others. DO NOT SHARE: I do not want any of the information about me in Minnesota’s HMIS shared with any other service providers/homeless agencies. I understand that not sharing my information may affect the ability to quickly and appropriately identify services for me.
When you sign this form, it shows that you understand the following.
• We will not deny you help if you do not want us to share your personal information. At the same time, sharing data does not guarantee that you will receive assistance.
• If you permit us to share your information, this consent is valid until canceled by you.
• If you permit us to share your information, you may change your mind and cancel this consent at any time. If you cancel this consent, your information will no longer be shared from that date forward.
Minnesota HMIS Data Sharing Authorization Signature *

Clear
HMIS Staff Signature

Clear
Please treat information about my children age 17 or younger the same as mine *

Yes No
Agency Staff: Sign if verbal consent for HMIS Sharing obtained by phone

Clear
Tennessen Warning

Data Privacy Rights for Applicants/Recipients of Program Sponsored By Evergreen Youth & Family Services
YOUR RIGHTS:

Under the Minnesota Data Privacy Act, you have the right to know how the information you provide on the application for a program will be used.
THE INFORMATION YOU PROVIDE WILL BE USED TO:

Determine your eligibility for a specific program, which requires sharing information with other Evergreen Youth & Family Services employees. Information gathered will also assist us in identifying other community based resources you may be eligible for.
REFUSAL TO PROVIDE DATA:

You may refuse to provide the data. This may prevent you from obtaining services from certain programs that require the data and our services to you may be limited. You do not have to provide a Social Security Number to be eligible for our programs. Federal Privacy Act and Freedom of Information Act dictate the use of the Social Security Number. We may use it for computer matches, programs reviews and audits. We will ask you for your Social Security number for these purposes only and will not share that information unless dictated by law.
AUTHORIZATION BY LAW TO SHARE INFORMATION

Evergreen Youth & Family Services is required bylaw to report aggregate statistical and demographic data on clients to state, federal and other federal monitors. Case files may be reviewed during required site visits. With your informed consent, we may also share it with community agencies, local and state human service agencies, local government, educational programs, Minnesota Housing Financial Agency, DHS-OEO, DHS Adolescent Services, DHS Supportive Services, LTH, HUD, and other agencies that help you.
By signing this you are acknowledging that you understand your data privacy rights and how information you share with this agency will be used. *

Clear
Staff Signature

Clear
Statement on Mandated Reporting
Staff employed at the Evergreen Youth & Family Services are mandated by law to report all “firsthand” information regarding physical, sexual, and/or emotional abuse, as well as neglect of youth under the age of 18 to Beltrami County Human Services and/or the Law Enforcement Center.
In the event an employeeof Evergreen suspects abuse, danger, and/or neglect, staff will:

Complete an Evergreen Youth & Family Services Maltreatment of Minors Report describing the details and nature of the reported abuse and/or neglect.
Forward the report within one business day to the intake worker at Beltrami County Human Services.
If the reported abuse constitutes imminent danger to a minor child, Evergreen staff will contact Beltrami County Law Enforcement Center.
If client reports abuse of child, unborn child, or vulnerable adult (developmentally disabled or elderly); staff will complete a Maltreatment of Vulnerable Adults form.
If client declares that they are going to cause harm to themselves or another person Evergreen staff will contact Bemidji Law Enforcement Center immediately.
I have read and understand the above information: *

Clear
Staff Signature

Clear
Legal Name *

First Name Last Name
Preferred Name
Date of Birth *

Month Day Year
Age *
Contact Information
Phone Number

Area Code Phone Number
Is it okay to leave a message? *

Yes No
E-mail
example@example.com
Name on Facebook
Address or City/State where currently staying *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Demographic Information

If you do not want to answer select "prefer not to disclose"
Gender Identity *

Male Female Transgender Male/Transman/FTM Transgender Female/Transwoman/MTF Does Not identify as Male/Female/Transgender Prefer not to disclose
Which pronouns do you use? *

She/Her He/Him They/Their Prefer not to disclose
Sexual Orientation: *

Heterosexual (straight) Homosexual Bisexual Questioning/Unsure Prefer not to disclose
How would you describe your race? (select all that apply) *

Am Indian/Alaskan Asian/Pacific Islander Black/African American Hispanic/Latino White/Caucasian
Are you: *

Hispanic/Latino Non-Hispanic/Latino Prefer not to disclose
Tribal Affiliation *

Yes No
If yes: Name of Tribe
Tribal Enrollment *

Yes No
If yes: Name of Tribe
Health
Do you currently have health insurance? *

Yes No
If yes, what type of insurance?
Do you have any disabilities/disorders/diagnoses? *

Yes No
If yes, type: *

Developmental Physical Mental Health Substance Use Prefer not to disclose
Dependents
Do you have children under the age of 18 in your care? *

Yes No
If yes, what are their ages?
What best describes your situation?

Single Parent/Caregiver Co-Parenting
Are you, or your significant other, currently pregnant? *

Yes No
If yes, expected due date?

Month Day Year
Date
Services Evergreen Provides
Which services are you interested? (Select all that apply) *

Wash/Dry Laundry Diapers/Wipes Shower Food Bag Hygiene Products Adulting/Parenting Skills Groups Mental Health Counseling None of the above
Do you have a: *

Social Security Card Birth Certificate State ID Tribal ID Driver's License Driver's Permit High School Diploma/GED None
Do you want to be contacted for getting any of these documents: Social Security Card, State ID, Driver's License, Birth Certificate, Tribal ID, Driver's Permit? *

Yes No
Would you like to be contacted for assistance obtaining your diploma/GED or further education (college or vocational training)? *

Yes No
Would you like to be contacted for assistance obtaining or maintaining employment? *

Yes No
Income & Employment
Do you have income or expect to have income within the next month (job or benefits)? *

Yes No
Do you currently have employment? *

Yes No
Employer name:blanks. Hourly wage:blank. Hours per week: .
Do you receive MFIP (Minnesota Family Investment Program) or TANF (Temporary Assistance for Needy Families) benefits?

Yes No
Amount per month:
Do you receive GA (General Assistance)?

Yes No
Amount per month:
Do you receive child support?

Yes No
Amount per month:
Do you receive Social Security benefits (SSI/ SSDI)?

Yes No
Amount per month:
Do you receive Tribal Income?

Yes No
Amount per month:
Do you receive SNAP Benefits (Food Stamps)?

Yes No
Amount per month:
Do you receive assistance from WIC? *

Yes No
Do you receive rental assistance from: *

Bi-Cap Section 8 Evergreen NWICDC None
Life Experiences
Have you ever been in foster care (group home, foster family, SAT home)? *

Yes No
Are you interested in being contacted about Independent Living Skills Program? *

Yes No
Have you experienced domestic violence? *

Yes No
If yes, when did the experience occur?
If yes, are you currently fleeing?

Yes No
Have you ever been the victim or secondary victim of a crime? (examples include abuse, assault, bullying/harassment, neglect, theft/robbery, violence, violence in your home, etc.) *

Yes No
Are you interested in being contacted about the Crime Victim Services program? *

Yes No
Have you ever had to exchange/trade sex for a place to stay, a ride, food, money, or any other basic need? *

Yes No
Are you interested in being contacted about Safe Harbor services? *

Yes No
Housing History
Are you experiencing any of the following: *

Homelessness/Couch Hopping Will be homeless within 2 weeks Not experiencing either of the situations above
Are you interested in being contacted about the Housing Program? *

Yes No
Do you need emergency financial assistance to continue living in your current housing or to move into housing for which you have been approved? *

Yes No

Welcome to Evergreen!

Minnesota's HMIS Data Privacy Notice

Tennessen Warning

YOUR RIGHTS:

THE INFORMATION YOU PROVIDE WILL BE USED TO:

REFUSAL TO PROVIDE DATA:

AUTHORIZATION BY LAW TO SHARE INFORMATION

Statement on Mandated Reporting

In the event an employeeof Evergreen suspects abuse, danger, and/or neglect, staff will:

Contact Information

Demographic Information

Health

Dependents

Services Evergreen Provides

Income & Employment

Life Experiences

Housing History

STAFF USE ONLY

External Referrals