Intake Form Macomb Client Intake Form 4 06 Intake Worker Intake Date by benbenzhou

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									                                                Macomb Client Intake Form (4.06)

Intake Worker: _______________________ Intake Date: ___________ Client ID Number: ______________

First Name: ____________________ MI _____________________ Last Name: ____________________ Suffix: _______

                                      HOUSEHOLD INFORMATION
                   ****** Complete this section for Clients in Households ONLY ******
Head of Household: □ Yes □ No
Household Type:
□ Female Single Parent □ 2 Parent Family □ Couple w/no Children             □ Male Single Parent         □ Other          □ Foster Parents
□ Grandparent and child □ Non-custodial caregiver □ Single Adult

Relationship to Head of Household: □ Self
□ Daughter                 □ Father                  □ Granddaughter          □ Grandfather            □ Grandmother       □ Grandson
□ Husband                  □ Mother                  □ other non-relative     □ other relative         □ Significant other
□ Son                      □ Stepdaughter            □ Stepson                □ Un-known               □ Wife

CLIENT PROFILE INFORMATION

Last 4 SS#: ___________            Date of Birth: _____________ Is Client Elderly? (Age 62 and older) □ Yes □ No

Gender: □ Female □ Male □ Transgender Ethnicity: □ Hispanic/Latino □ Non-Hispanic/Non-Latino □ Don’t Know □ Refused

Primary/Secondary Race:
□   White     □   American Indian/Alaskan Native and Black      □   American Indian/Alaskan Native and White              □ Alaskan Native
□   Black     □   Black/African American and White              □   Asian and White                                       □ Other Multi-racial
□   Asian     □   American Indian                               □   Native Hawaiian                                       □ Pacific Islander
□   Other     □   Don’t Know                                    □   Refused

Marital Status: □ Divorced □ Married □ Separated □ Single □ Widowed □ Living with Sig. Other/Partner

Valid Drivers License? □ Yes □ No                      ID Number: ______________________________________________

Means of Transportation: □ Handicapped Transportation □ Bicycle □ Family/friends □ Walks □ Owns car □ Taxi □ Uses the bus

Institutional Living Prior to 18 Years? □ Yes □ No

                                       DISABILITY INFORMATION
Health Condition compared to people your age: □ Excellent □ Very Good □ Good □ Fair □ Poor □ Don’t Know □ Refused

Do you have a disability of long duration? □ Yes                □ No        □ Don’t Know         □ Refused

Disability Sub-assessment
□   Alzheimer’s/Dementia          □   Cognitive         □ Learning Disability        □   Mental Handicap/Injury           □ Speech
□   Alcohol Abuse                 □   Both Alcohol and Drug Abuse                    □   Chronic Health Condition         □ Developmental
□   Drug Abuse                    □   Physical/Medical □ Mental Health Problem       □   Physical                         □ HIV/AIDS
□   Hearing Impaired              □   Vision Impaired   □ Dual Diagnosis             □   Other

Disability Determination? □ Yes □ No □ Don’t Know □ Refused

Currently Receiving Services or Treatment? □ Yes □ No □ Don’t Know □ Refused

Disability Start Date: _______________


Note of Disability:____________________________________________________________________________________


Receiving Social Security Benefits? □ Yes □ No
Has Client applied for SSI/SSDI? □ Yes □ No                     Outcome? □ Approved □ Denied
Are you pregnant?     □ Yes □ No                                If “yes”, projected Birth date: ____________________________
                                                                                                                               Revised 01/04/2010
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Is Juvenile parent?          □ Yes □ No

Domestic violence survivor? □ Yes □ No □ Don’t Know                         □ Refused

Extent of Domestic Violence:
□ Within the past 3 months               □ 3-6 months ago          □ 6-12 months ago        □ More than 1 year ago □ Don’t Know           □ Refused

                                          INCOME INFORMATION
Income received from any source in the past 30 days? □ Yes □ No                                    □ Don’t Know       □ Refused

Last 30 Day Income: ________________

Source of Income:
□ A Veteran’s Disability Payment                  □   Alimony or other Spousal Support             □   Annuities      □ Child Support
□ Cont. from other people                         □   DHS Cash Assistance                          □   Dividends      □ Earned Income
□ Interest (Bank)                                 □   No Financial Resources                       □   Other          □ Pension from a former job
□ Pension/Retirement                              □   Private Disability Insurance                 □   Railroad Retirement
□ Rental Income                                   □   Retirement Disability                        □   Retirement Income from Social Security
□ Self Employment Wages                           □   SSDI                                         □   SSI            □ State Disability
□ TANF                                            □   Unemployment Insurance                       □   Veteran’s Pension
□ Worker’s Compensation

Non Cash benefit received from any source in past 30 days?                              □ Yes      □ No      □ Don’t Know        □ Refused

Source of Non-Cash Benefit:
□ Supplemental Nutrition Assistance Program (Food Stamps) □ MEDICAID         □ MEDICARE      □ SCHIP
□ Special Supplemental Nutrition Program for WIC          □ Veteran’s Admin (VA) Medical Services
□ TANF Child Care Services                                □ TANF Transportation Services □ Other TANF Funded Services
□ Section 8, Public Housing or Rental Assistance          □ Other Source

Start Date of Benefits: _____________________

                                                         EMPLOYMENT INFORMATION
Currently EMPLOYED? □ Yes                  □ No            If unemployed, looking for work? □ Yes                    □ No

                             ****** Complete this section for EMPLOYED CLIENTS ONLY ******

Hours worked last week? _______ Tenure: □ Permanent □ Temporary □ Seasonal                                            □ Don’t Know        □ Refused

Status: □ Full Time           □ Part Time         □ Retired           □ Seasonal        □ Volunteer          □ Maternity Leave

Employer Information:

                                                            EDUCATION SUMMARY
Highest level of education attained:
□   No Schooling Completed           □   Nursery School to Fourth Grade                 □   5th grade or 6th grade    □   7th grade or 8th grade
□   9th grade                        □   10th grade                                     □   11th grade                □   12th grade
□   Less than High School            □   Some High School                               □   High School Diploma       □   GED
□   Some College                     □   College degree                                 □   Graduate degree           □   Some Technical
□   Technical School Certification   □   Don’t Know                                     □   Refused

Currently in School or working on any Degree?                         □ Yes □ No        Received vocational training? □ Yes □ No

Degrees Earned? _________________________________________________________________________________

                                                                VETERAN DETAIL

U.S. Military Veteran?                   □ Yes              □ No              □ Don’t Know                   □ Refused

                                                                                                                                      Revised 01/04/2010
                                                                                                                                              Page 2 of 4
                   ****** Complete this section for US Military Veterans ONLY ******
Months Served on Active Duty in the Military _____________

Discharge Type:            □ Honorable □ General □ Medical □ Bad Conduct □ Dishonorable □ Other

Military Service Related Disability?              □ Yes □ No    □ Don’t Know     □ Refused
Receiving Veteran’s Services? □ Yes               □ No □ Don’t Know      □ Refused
If Yes, List Veteran’s Services:

                             HURRICANE KATRINA QUESTIONS (ESG Required)
Hurricane Katrina Evacuee? □ Yes □ No             If “yes”, homeless prior to Katrina? □ Yes □ No

Unaccompanied Youth? □ Yes □ No
                                          HOMELESS INFORMATION
                                 ******Shared Household Information******
Is Client Homeless? (by HUD definition) □ Yes □ No

Housing Status:
□ Literally Homeless
□ Housed and at imminent risk of losing housing
□ Housed and at-risk of losing housing
□ Stably Housed
□ Don’t Know
□ Refused
                        ****** Complete this section for HOMELESS CLIENTS ONLY ******

Is Client Chronically Homeless?                  □ Yes    □ No (by HUD definition? MUST be single, AND have a disability)

Homeless Primary/Secondary Reason: (MUST select two)
□   Criminal activity           □   Domestic violence □ Loss of transportation          □ Health/safety □ Loss of childcare
□   Loss of job                 □   Eviction           □ Loss of public assistance      □ Medical condition □ Mental health
□   Mortgage foreclosure        □   Utility shutoff    □ No affordable housing          □ Release from institution
□   Substance abuse             □   Substandard housing         □ Under employ/low income

Extent of Homelessness:
□ First time homeless       □ 1-2 times in the past      □ Chronic: 4 times in past 3 years    □ Long term: 2 years or more

Explain Homeless situation: ______________________________________________________________

Date of present homelessness: ______________

Referred from:
□   Alcohol/Drug Program              □   Emergency Shelter       □   Family or Friend                 □   Family Resource Center
□   Health Care Provider              □   Homeless Coalition      □   Info & Referral Service/ 211     □   Mental Health Outpatient
□   Police or Law Enforcement         □   Prisoner Re-entry       □   Social Service Organization      □   Michigan WORKS!
□   School                            □   Street Outreach         □   Self                             □   Church
□   OTHER
                                              PRIOR LIVING SITUATION
Prior Living Situation (Where was the client last night?)
□ Don’t Know
□ Foster Care/Group Home
□ Owned by client, no housing subsidy
□ Subsidized Housing
□ Refused
□ Rental by client, no subsidy
□ Jail, Prison or Juv. Facility
□ Hospital (non-psychiatric)
□ Emergency Shelter, including hotel or motel paid w/ voucher
         Shelter Name: (where client stayed last night)____________________________________________
□ Staying or Living with Family                                                  ….continued on next page
                                                                                                                               Revised 01/04/2010
                                                                                                                                       Page 3 of 4
□ Staying or Living with Friends
□ Permanent Housing for formerly Homeless
□   Place not meant for habitation
□   Transitional Housing for homeless (including homeless youth)
□   Psychiatric Hospital or other Psychiatric Facility
□   Substance Abuse Treatment facility or Detox Center
□   Other
□   Hotel or Motel paid for w/o voucher
□   Safe Haven
□   Rental by client, with VASH housing subsidy
□   Rental by client, with other (non-VASH) housing subsidy
□   Owned by client, with housing subsidy

Length of Stay: □ One week or Less □ 1 week to 1 month           □ 1-3 months □ 3 months to 1 year                  □ One year +
(Length of stay is how long client was in the above mentioned living situation)

Zip Code of Last Permanent Address: ____________City: ____________________County: _____________________

Homeless Verification on File: □ Formal Eviction documentation             □ Signed client statement w/confirm statement
□ Verification from Institution        □ Verification from Outreach Worker □ Verification from referring agency

Actual or pending eviction/foreclosure? □ Yes □ No                  If yes, date of eviction/foreclosure:_______________

Number of clients in Household being served today: _________

                                         ****** ESG REQUIRED INFORMATION ******
                                                  HOUSING STATUS DETAIL
Home Owners:
Facing significant back taxes or mortgage payments? □ Yes □ No

In Rental House/Apartment:
50% or more of income is spent on housing? □ Yes □ No                          Facing significant back rent? □ Yes □ No
Living in substandard unit w/code violations? □ Yes □ No                       Facing back utilities &/or shutoff? □ Yes □ No

Living with Family or Friends:
Temp. Doubled up due to housing crisis? □ Yes □ No                 Doubled up facing eviction? □ Yes □ No
History of being doubled up:
□ Never        □ 1 or 2 times for less than 1 mo. □ 1 or 2 times for more than 1 mo.    □ Often doubled up
Length of time doubled up?
□ One week or Less     □ > 1 week, < 1 month      □ 1-3 months □ > 3 months, < 1 year           □ One year +

Other Places:
Exiting Institution w/no housing plan? □ Yes □ No                      Living in places not meant for habitation? □ Yes □ No
Living in hotel/motel paid for by program? □ Yes □ No                  Temporarily residing in shelter (ES or TH)? □ Yes □ No
Living in permanent supportive housing? □ Yes □ No

Total HH monthly income ________________                      % of Median Income: □ 0-30% □ 31-50% □ 51-80% □ over 80%
                                                                                          *Use county chart to determine median income range

                                               EMERGENCY CONTACT INFORMATION

Name: ____________________                    Phone: _________________ Relationship to you: ______________

Add: _____________________ City/State/Zip: ___________________Last Contact Date: ____________




                                                                                                                         Revised 01/04/2010
                                                                                                                                 Page 4 of 4

								
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