Alamance County Joblink Career Center

Document Sample
Alamance County  Joblink Career Center Powered By Docstoc
					                                                                      EXPIRATION DATE_____________________________




                              CHIN HMIS SHARING EXCEPTIONS FORM

                                     ___________________________
                                             (Client or Dependent’s Name)



This form should be used when you agree to have your and/or your dependent’s information entered
into the system but (1) you want to limit what is shared with other agencies AND/OR (2) you want to
limit what agencies may view your information. Please understand that access to shelter and housing
services is available whether or not you consent to the sharing of your information with some or all
agencies.

Please complete a separate form for each dependent whose information will be entered into the CHIN
HMIS.

Make an X next to the items you DO NOT want shared with other participating agencies:

ADDITIONAL PERSONAL INFORMATION
Race / Ethnic Origin                                         Veteran’s Status
Driver’s License/State ID Number                             Issuing State for ID
Zip code of last permanent address                           Identifying marks/Clothing
Photo, if the agency includes photos as part of              Notifications and Alerts, if they pertain to
its intake                                                   medical emergency or recent violent criminal
                                                             activity
SERVICE INFORMATION:
Program Entry and Exit Information                           Shelter Stays
Food                                                         Clothing
Transportation                                               Financial Assistance
Employment                                                   Housing
Utility Assistance                                           TB Clearance Status

*Make an X next to the agencies you DO NOT want to view your information:


                       Affordable Housing Coalition of
      Buncombe         Asheville                                       Vance          Life Line Outreach
      Forsyth          AIDS Care Service                               New Hanover    LINC, Inc.
      Alamance         Alamance Caswell Rockingham LME                 Gaston         Living Water CDC, Inc.
                       Alamance County Dept of Social
      Alamance         Services                                        Guilford       Loaves & Fishes Christian Food Ministry
                       Albemarle Coalition to End
      Camden           Homelessness                                    Rowan          Love Center for Community Enhancement
      Vance            Alliance Rehabilitative Care (Men’s             Guilford       Mary's House, Inc.
              Shelter
Alamance      Allied Churches Emergency Shelter          McDowell      McDowell Mission Ministry
New Hanover   ARC of North Carolina, The                 Burke         Meeting Place Mission
Gaston        As One Ministries                          Wake          Mental Health Association
              Asheville Buncombe Community
Buncombe      Christian Mission                          Haywood       Mountain Projects Comm. Action Agency
                                                                       Mountain Youth Resources Hawthorne
Buncombe      Asheville Housing Authority                Jackson       Height
Forsyth       Bethesda Center for the Homeless, Inc.     Murphy        Murphy Emer. Shelter (Friendship House)
Brunswick     Brunswick Family Assistance                New Hanover   NAMI of Wilmington, NC
Burke         Burke United Christian Ministries          Statewide     NC DHHS
              Cape Fear Housing for Independent
New Hanover   Living                                     Watauga       New River Behavioral Health Care
Guilford      Caring Services of High Point, Inc.        Wilkes        Northwestern Regional Housing Authority
Mecklenburg   Carolina Behavioral Health Care            Gaston        Off the Streets
Caswell       Caswell County Section 8 Program           Orange        OPC Area Program/LME
Gaston        Catherine's House (Sisters of Mercy)       Guilford      Open Door Ministries of High Point
Forsyth       CenterPoint Human Services                 Forsyth       Partnership for a Drug Free NC
Cherokee      Cherokee County DSS                        Iredell       Partnership for Behavioral (Insight/Path)
              Christian Counseling and Wellness
Guilford      Group                                      Gaston        Pathways LME
Randolph      Christians United Outreach Center          Cabarrus      Piedmont Behavioral Healthcare
Orange        Chrysalis Foundation for Mental Health     Buncombe      Pisgah Legal Services
Cumberland    City Rescue Mission, Inc. (Fayetteville)   Pitt          Pitt County DSS
              Cleveland County Abuse Prevention
Cleveland     Council                                    Pitt          Pitt County Planning (Comm. Dev.)
New Hanover   Coastal Horizons Center                    Pitt          PORT Human Services
              Cooperative Christian Ministry of
Cabarrus      Cabarrus                                   Cabarrus      Prosperity Ministries
Gaston        Cornerstone Christian Center               Randolph      Randolph County Joblink Career Center
Davidson      Crisis Ministry of Davidson (Noonan)       Rockingham    Reidsville Housing Authority
Surry         Crossroads Behavioral Health Care          Rockingham    Reidsville Outreach Center
              Cumberland County (Community
Cumberland    Development)                               Gaston        Reinvestments in Communities
              Cumberland Interfaith Hospitality
Cumberland    Network                                    Craven        Religious Comm. Services of New Bern
Cumberland    Cumberland Mental Health                   Alamance      Residential Treatment Services
Iredell       Diakonos                                   Richmond      Richmond County Mental Health Society
Pitt          East Carolina Behavioral Health            Durham        Right Track Health Services
Wayne         Eastpointe LME                             Rockingham    Rockingham County DSS
Surry         Echo Ministry (The Ark)                    Rockingham    Rockingham County Help for the Homeless
              Exodus Outreach Foundation Exodus
Catawba       Homes                                      Rowan         Rowan Helping Ministries
Forsyth       Experiment in Self Reliance                Gaston        S.L.I.D.E.S. Inc
Halifax       Faith House of Enfield                     Buncombe      Salvation Army of Asheville
              Family Care Center of Catawba Valley,
Catawba       Inc                                        Rockingham    Salvation Army of Eden
Guilford      Family Service of the Piedmont             Cumberland    Salvation Army of Fayetteville
New Hanover   First Fruit Ministries                     Gaston        Salvation Army of Gastonia
Vance         Five County Mental Health Authority        Wayne         Salvation Army of Goldsboro
              Flynn Christian Fellowship Home Pitt
Pitt          Co                                         Guilford      Salvation Army of Greensboro
Gaston        Gaston County Interfaith                   Catawba       Salvation Army of Hickory
Gaston        Gaston Residential Services                Guilford      Salvation Army of High Point
New Hanover   Good Shepherd Ministries                   New Hanover   Salvation Army of Wilmington
Cabarrus      Grace and Mercy House                      Forsyth       Salvation Army of Winston-Salem
Alamance      Graham Housing Authority                   Forsyth       Samaritan Ministries
     Surry           Greater Mt. Airy Ministry of Hospitality   Moore           Sandhills Community Action
     Lenoir          Greene Lamp, Inc.                          Lee             Sanford Housing Authority
     Guilford        Greensboro Housing Coalition               Guilford        Servant Center
     Guilford        Greensboro Urban Ministry                  Jackson         Smoky Mountain Center
     Pitt            Greenville Community Shelters              New Hanover     Southeastern Center-Sherwood
                                                                                Surry Homeless & Affordable Housing
     Pitt            Greenville Housing Authority               Surry           Coal.
                     Guilford County Interfaith Hosp.
     Guilford        Network                                    Beaufort        Tidelands Mental Health Center
     Granville       Harbour House Oxford, NC                   Union           Union County Community Shelter
     Guilford        High Point Housing Coalition               Nash            United Community Ministries
     Cabarrus        Higher Level Missions                      Forsyth         United Way of Forsyth County
     Stanly          Homes of Hope                              Wake            Wake County Human Services
     Buncombe        Homeward Bound of Asheville (AHOPE)        Watauga         WAMY Community Action
     Forsyth         Hosanna House of Transition                Wilson          Wesley Shelter, Inc.
     Watauga         Hospitality House of Boone                 Guilford        West End Ministries
     Durham          Housing for New Hope                       Buncombe        Western NC Comm. Health Serv.
                                                                                Wilmington Housing Finance &
     Forsyth         Insight Human Services                     New Hanover     Development
     Orange          Inter-Faith Council for Social Services    New Hanover     Wilmington Interfaith Hospitality Network
     Iredell         Iredell-Statesville Schools                Gaston          With Friends, Inc. (Adam's House)
                     Johnston-Lee-Harnett Community
     Johnston        Action                                     Forsyth         WS/FC Schools
                     Joy Shabazz Center for Independent
     Alamance        Living                                     Guilford        Youth Focus, Inc.
     Burke           Kwanzaa Family Inn                         Vance           Life Line Outreach



OR
Initial here if you do not want ANY other agency to view your information: _______



Date:_____________                  Signature:                                                           ______


                                    Name (Print):                                                        ______


Date:_____________                  Agency Witness:



*Please note that agency participation in the Carolina Homeless Information Network is dynamic and agencies may
be added or deleted without notice. An updated membership list is published periodically on the CHIN web site at
www.nchomeless.org. Click the “Member Agencies” tab. All membership inquires should be directed to H. E.
“Hunter” Thompson at (919) 827-4500.

				
DOCUMENT INFO
Description: Alamance County Joblink Career Center document sample