First Name
Middle Name
Last Name
Preferred pronoun
Preferred Name
Birth date
-
Month
-
Day
Year
Date Picker Icon
Social Security Number
Phone number
What is your preferred Method of Contact
Email
Text Phone
Email address
Current address (if applicable)
Preferred Language
Ethnicity
Hispanic/Latino
Non-Hispanic/Latino
Client Doesn't Know
Client Refused
Race (Select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic/Latino
Client Doesn't Know
Client Refused
Gender
Please Select
Male
Female
Transgender Female to Male
Transgender Male to Female
Client Doesn't Identify Male, Female, or Transgender
Non-binary
Gender Non-conforming
Client Doesn't Know
Client Refused
Sexual Orientation
Homosexual
Bisexual
Heterosexual
other
Martial Status
Married
Married with Child(ren)
Single
Single with Child(ren)
Divorce
Separated
Widow
Age / Gender of Child(ren)
Pregnancy Status
Yes
No
Client Doesn't Know
Client Refused
Pregnancy If Yes, Due Date?
-
Month
-
Day
Year
Date Picker Icon
Veteran Status
Please Select
Yes
No
Client Doesn't Know
Client Refused
Data Not Collected
Services Needed
Housing
Shelter
Rental Assistance
Medical
Food
Treatment
Care
Mental Health
Substance Use
Documents
Other
Employment
Other
Type of HOPWA Housing
Shared Living
Single Unit
Substance Abuse Housing Program
Transitional 2 year program (Shared)
Permanent Housing Placement (PHP)
TBRA (Income with apartment,income with welcome letter
Master Lease
Step 2: Entry Assessments
Disabling Condition
Please Select
Yes
No
Client Doesn't Know
Client Refused
Data Not Collected
Current Location (The CoC the client is being served in)
Please Select
Athens/Clarke County (GA-503)
Atlanta (GA-500)
Augusta (GA-504)
Columbus/Russell County (GA-505)
Dekalb County (GA-508)
Fulton County (GA-502)
Balance of State (GA-501)
Marietta/Cobb (GA-506)
Savannah/Chatham County (GA-507)
Step 3: Living Situation
Living Situation - Identify the residence just prior to (i,e., the night before) enrollment (Only Select One)
Homeless Situation
Please Select
Place not meant for habitation
Emergency shelter, including hotel or motel paid for with emergency shelter voucher
Safe Haven
On the street
Institutional Situation
Please Select
Foster care home or foster care group home
Hospital or other residential non-psychiatric medical facility
Jail, Prison or Juvenile Detention Center
Long-term care facility or nursing home
Psychiatric hospital or other psychiatric facility
Substance Abuse Treatment Facility or Detox Center
n/a
Transitional and Permanent Housing Situation
Please Select
Hotel or motel paid for without emergency shelter
Owned by client NO on going housing subsidy
Owned by client WITH on going housing subsity
Permanent Housing (other RRH) of Formerly ?????
Rental by client with NO ongoing housing subsidy
Rental by client with no VASH housing subsidy
Rental by client with GPD TIP Subsidy
Rental by client with other ongoing housing housing subsidy
Residential project or halfway house with no home???????
Staying or living in a family member's room, apartment, ????????
Staying or living in a friend's room, apartment, ????????
Transitional housing for homeless persons
Client Doesn't Know
Client Refused
N/A
Length of stay in this living situation?
Would you prefer sober living?
Housing Treatment Program
Step 4: History of Homelessness
Approximate date homelessness started (The beginning of this continuous period of homelessness)
Total # of times the client has been on the streets, in ES, or SH in the past three years including today
Total # of months homeless on the streets on the streets, in ES, or SH in the past three years
Step 5: Historical Program Enrollment
Please list all previous programs client previously enrolled. Include dates, duration of enrollment, and county/city
Previous Program Enrollments
Step 6: Health Insurance
Private
Medicare
Medicaid
ADAP
Ryan White
Military Insurance
Indian Health Service
Client Doesn't Know
Client Refused
None
Step 7: Barriers/Special Needs
Identify whether a client has each individual barrier or not
*
No
Yes
Client Refused
Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently?
Expected to substantially impair ability to live independently?
N/A
Alcohol Abuse
Chronic Health Condition
Developmental Disability
Drug Abuse
HIV/AIDS
Mental Health
Physical Disability
Step 8: Criminal History
*
No
Yes
Client Refused
Misdemeanor
Felony
Sex Offender
Meth Charge
Step 9: Domestic Violence
Has the client been a victim of Domestic Violence?
Please Select
Yes
No
Client refused
Client doesn't know
Data not collected
When did the experience occur?
Please Select
With in the past three months
Three to six months ago (excluding 6 months exactly)
Six months to one year ago (excluding 1 year exactly)
One year ago or more
Client Doesn't know
Client Refused
Data not collected
Is the client currently fleeing?
Please Select
Yes
No
Client doesn't know
Client refused
Data not collected
Step 10: Medical Assistance
Only required for those with HIV/AIDS
Are you currently in medical care for HIV
Yes
No
Applied
Yes
No
Client doesn't know
Client refused
Receiving public HIV/AIDS medical assistance?
If no:
Please Select
Applied; decision pending
Applied; client not eligible
Client did not apply
Insurance type n/a for this client
Client refused
Data not collected
Yes
No
Client doesn't know
Client refused
Receiving AIDS Drug Assistance Program (ADAP)?
If no:
Please Select
Applied; decision pending
Applied; client not eligible
Client did not apply
Insurance type n/a for this client
Client refused
Data not collected
Step 11: Income and Non-Cash Benefits
Income Sources:
Please Select
No Income
Client Refused
Client doesn't know
Data Not Collected
If client has income
Earned Income (i.e., employment income)
Unemployment Insurance
Social Security Disability Insurance (SSDI)
Veteran's Disability Payment
Private Disability Insurance
Worker's Compensation
Temporary Assistance for Needy Families (TANF)
General Assistance
Retirement income from Social Security
Veteran's Pension
Child Support
Alimony or other spousal support
Other
Earned Income (i.e. employment income)
Unemployment Income (i.e., employment income)
Supplemental Security Disability (SSI)
Social Security Disability Payment (SSI)
Veteran's Disability Payment
Private Disability Insurance
Worker's Compensation
Temporary Assistance for Needy Families (TANF)
General Assistance
Retirement income from Social Security
Veteran's Pension
Other Pension
Child Support
Alimony or other spousal support
Other income
Non-Cash Benefit Sources
No non-cash benefits
Client refused
Client doesn't know
Data not collected
If client receives non-cash benefits, check all that apply
Supplemental Nutrition Assistance Program (SNAP) (Food Stamps)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
TANF Child Care Services
TANF Transportation Services
Other TANF-funded Services
Other Source (please specify in next section)
SNAP/Food Stamp amount (if receiving)
Other Source type
Other Source amount (if receiving)
Note
Referred By
Submit
Should be Empty: