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					    HMIS Entrance Form                                                       BCC/BCP Programs

                       HMIS Youth Program Entrance Form
                             Basic Center Program
    Entrance Date: ________________________                Intake Worker:__________________________

    First Name____________________________*MI ____ *Last Name______________________________

    *Date of Birth __________________ (mm/dd/yyyy) *SS# ______________________________________

    Basic Demographic Information
    Date of Birth Type:
    □ Full DOB Reported (HUD)     □ Approximate or Partial DOB Reported (HUD)
    □ Don‘t Know (HUD)            □ Refused (HUD)

    Parent engagement in care
    □ Limited   □ Moderate □ Strong         □ No Involvement   □ Unknown

    *Gender
                 Male
                 Female
                 Transgender Female to Male
                 Transgender Male to Female
                 Other
                 Don‘t Know

*Primary Race
     □ American Indian or Alaskan Native              □ White (HUD)
     □ Native Hawaiian or other Pacific Islander      □ Other
     □ Asian                                          □ Other Multi-racial
     □ Black or African American (HUD)

*Ethnicity
             Hispanic/Latino
             NonHispanic/Non-Latino
             None Specified
             Don‘t Know
             Refused

Sexual Orientation: Choose one code indicating how the youth describes his/her sexual orientation.
Heterosexual _______ Gay _______ Lesbian _______ Bisexual_______
Questioning/Unsure _______    Not Known or Not Determined ______

*US Military Veteran
        □Yes (HUD)                                                 □ Don‘t Know (HUD)
        □ No (HUD)                                                 □ Refused (HUD)

    Domestic violence victim?                              *Extent of Domestic Violence
          □ Yes                                                    □ Within the past three months
          □ No                                                     □ Three to six months ago
          □ Don‘t know                                             □ From six to twelve months ago
          □ Refused                                                □ More than a year ago
                                                                   □ Don‘t know
                                                                   □ Refused
  HMIS/RHYMIS Entrance Form                                                  BCC/BCP Programs


  Pregnant/Parenting Teen Information

   Pregnant or Teen Parent: Is the youth currently pregnant or the parent of a child?

       ______Yes
       ______No
       ______Do not know

  Is Juvenile Parent? □ Yes □ No

  If yes and the youth is a parent, please provide the following information for each child:
  Child‘s Name:_____________________________________________________________________
  Child‘s Date of Birth__________________________________________________(mm/dd/yyy)
                                                         __________ Female
                                                         This Child is currently in the youth‘s care:
  Child‘s Gender                                         ___________Yes
  __________ Male                                        ___________No

  Child‘s Name:_____________________________________________________________________
  Child‘s Date of Birth__________________________________________________(mm/dd/yyy)

  Child‘s Gender                                          This Child is currently in the youth‘s care:
  __________ Male                                         ___________Yes
  __________ Female                                       ___________No

  Child‘s Name:_____________________________________________________________________
  Child‘s Date of Birth__________________________________________________(mm/dd/yyy)

  Child‘s Gender                                          This Child is currently in the youth‘s care:
  __________ Male                                         ___________Yes
  __________ Female                                       ___________No

  Disability Information
  *Do you have a disability of long duration?
       □ Yes (HUD)     □ No (HUD)       □ Don‘t Know (HUD)           □ Refused (HUD)

  *Disability Sub-assessment
Disability Type         Disability Determination        If yes, Currently receiving     Start     Long Term
                                                        services or treatment?          Date      Condition?
                        Yes     No    Don‘t   Refused   Yes No       Don‘t    Refused
                                      Know                           Know
Other:
Alzheimer/Dementia
Other: Cognitive
Other: Learning
Other: Mental
Handicap/Injury
Other: Speech
Alcohol Abuse (HUD)
Both alcohol and drug
abuse (HUD)
Chronic Health
Condition
Developmental
Drug Abuse
Physical/Medical
Mental Health Problem



   Revised                                         2                                       8/8/2011
       HMIS/RHYMIS Entrance Form                                                                        BCC/BCP Programs

    Physical
    HIV/AIDS
    Hearing Impaired
    Vision Impaired
    Dual Diagnosis
    Other

       Foster Care Information
       Youth in Foster Care?
           Yes                                               No                                              Past

       If past, how old was the youth when he/she exited foster care (for youth in care multiple times, record the
       youth’s age at most recent exit) _______________

       Youth Impacted by a Disrupted/Broken Adoption?
           Yes                                                                    No

    Youth Impacted by a Disrupted/Broken Guardianship?
          Yes                                               No
Former, not current, ward of the state child welfare agency: NOTE: FYSB funds are not intended to support youth
who are presently wards of the state (for whom the state is legal guardian) due to current foster care/child welfare status (e.g., ―system
youth‖). However, some youth previously in foster care have been discharged from that system or have reached an age of legal
independence in your state. (Specific rules about age, etc., vary by state.) Such youth are no longer a public responsibility and can be
helped by the FYSB BCP. For youth of this type, please answer the following question:

If the youth is no longer a state ward but was in foster care previously in his or her life, please enter the number of months or the
codes describing the number of years the youth has previously been in the care of the State:
               NO     If the youth is no longer in the system but was in foster care previously in his or her
               YES    life, please select YES to indicate the youth is a former ward of the state child
                      welfare agency
          Number of months:
          _____ Not applicable (more than 11 months (enter years below) or never in child welfare or foster care)
          _____ Number of Months (enter 1-11 for the number of months in child welfare or foster care)

          Number of years (if over 12 months, check one):
          _____ Not Applicable (less than 1 year- enter months above or never in child welfare or foster care)
          _____(1 – 2)
          _____(3 – 5)
          _____(More than 5)

Youth who is a former, not current, ward of the public juvenile justice system: NOTE: FYSB funds are not
intended to support youth who are presently wards of the state (for whom the state is legal guardian) due to current juvenile justice status
(e.g., ―system youth‖). However, some youth previously under the supervision or care of juvenile justice agencies have been discharged
from that system or reached an age of legal independence in your state. (Specific rules about age, etc., vary by state.) Such youth are no
longer a public responsibility and can be helped by the FYSB BCP. For youth of this type, please answer the following question:

If the youth is no longer a state ward but was in the care of the juvenile justice system previously in his or her life, please enter
the number of months or the codes describing the number of years the youth has previously been in the care of the State:
             NO     If the youth is no longer in the system but was in foster care previously in his or her
             YES    life, please select YES to indicate the youth is a former ward of the state child welfare
                    agency
          Number of months:
          _____ Not applicable (more than 11 months (enter years below) or never in child welfare or foster care)
          _____ Number of Months (enter 1-11 for the number of months in child welfare or foster care)

          Number of years (if over 12 months, check one):
          _____ Not Applicable (less than 1 year- enter months above or never in child welfare or foster care)
          _____(1 – 2)



        Revised                                                      3                                                  8/8/2011
HMIS/RHYMIS Entrance Form                                                                            BCC/BCP Programs

  _____(3 – 5)
  _____(More than 5)

Living Situation At Entry

*Is Client Homeless? (by HUD definition)
     □ Yes    □ No

Housing Status:
□ Literally Homeless                                                       □ Stably Housed
□ Housed and at Imminent risk of losing housing                            □ Don't Know
□ Housed and at risk of losing housing                                     □ Refused


Is Client Chronically Homeless? (by HUD definition)
                                 An unaccompanied homeless individual with a disabling condition who has either been continuously homeless for
                                 a year or more OR has had at least four (4) episodes of homelessness in the past three (3) years. The individual
      □ Yes        □ No          must have been on the streets or in an emergency shelter (not transitional housing) during these episodes.


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

Prior Living Situation (Where was the client last night?)
      □ Adult Foster Care                                            □ Don‘t Know
      □ Emergency Shelter, including hotel or motel
      paid for with emergency shelter voucher                        □ Foster care home or foster care group home
                                                                     □ Hotel or motel paid for without emergency shelter
      □ Hospital (non-psychiatric)                                   voucher
      □ Jail, Prison or Juvenile Facility                            □ Other
      □ Owned by Client, no housing subsidy (Select if               □ Owned by client, with housing subsidy (Select if client
      client was living with his/her parents and the                 was living with his/her parents and the family is
      family is not receiving housing subsidy)                       receiving housing subsidy)
      □ Permanent Housing for formerly homeless                      □ Place not meant for habitation inclusive of ‗non-housing
      persons (such as SHP, S+C or SRO Mod Rehab)                    service site (outreach programs only)
      □ Psychiatric Hospital or other psychiatric facility           □ Refused
      □ Rental by client, no housing subsidy                         □ Rental by client, with other (non-VASH) housing subsidy
      □ Rental by client, with VASH housing subsidy                  □ Safe Haven
      □ Staying or living in a family member‘s room,
      apartment or house (Select if client was living                □ Staying or living in a friend‘s room, apartment or house
      with extended family)                                          (Select if client was staying with non-related friends)
      □ Substance Abuse Treatment Center                             □ Transitional Housing for Homeless inc. youth

Length of Stay
       □ One week or less (HUD)
       □ More than one week, but less than one month (HUD)
       □ One to three months
       □ More than three months, but less than one year
       □ One year or longer
       □ Don‘t Know
       □ Refused

Living situation at entry: Choose one code to indicate the living situation in which the youth spent at least 6 of the 12
months prior to entrance. (If the youth did not spend more than 6 months at one residence during the 12 months prior to entrance,
enter the code corresponding to the residence in which he or she spent the most time during that period.




Revised                                                        4                                                       8/8/2011
    HMIS/RHYMIS Entrance Form                                                                       BCC/BCP Programs

    1. ______ In a shelter
1    FYSB Basic Center               FYSB-funded program providing core services (shelter, food, clothing, counseling) to runaway
                                     and homeless youth. Basic Center services may be provided in one central location, such as
                                     a group home residence, or in decentralized locations, such as host homes. Federal
                                     guidelines dictate that youth may stay at Basic Centers for up to 2 weeks using FYSB
                                     funding.
2    Other Youth Emergency           Non-FYSB-funded program providing core services (shelter, food, clothing, counseling) to
                                     runaway and homeless youth. Shelter services may be provided in one central location, such
     Shelter
                                     as a group home residence, or in decentralized locations, such as host homes.
3    Homeless Family Center          A program designed to provide shelter and services to homeless families.

4    Homeless Shelter                A program designed to provide shelter and services to homeless individuals.

5    Other Temporary Shelter         A shelter not described by any of the above that provides a temporary place to sleep.




    2. ______ On the street
1    On the street as a              The young person is on the street or in a facility that has become an informal shelter for
                                     runaway and homeless youth and adults. (The informal shelter may be an apartment the
     runaway or homeless
                                     leaser allows to be used, an abandoned building, a 24-hour business, or another location. It
     youth.                          usually is temporary, and may be operating illegally.)
2    On the street as a              The young person was told to leave a stable residence by a parent or guardian, or the parent
                                     or guardian knew the young person was leaving but did not care. The young person is now on
     throwaway youth
                                     the street or in a facility that has become an informal shelter for runaway and homeless youth
                                     and adults. (The informal shelter may be an apartment the leaser allows to be used, an
                                     abandoned building, a 24-hour business, or another location. It usually is temporary, and may
                                     be operating illegally.)

    3. ______ In a Private Residence
1    Living Independently       The youth lives on his/her own and has an address.

2    Parent/Legal Guardian's         The residence of the biological parent(s), adoptive parent(s), legal guardian, or parent who is
                                     not the youth's legal guardian.
     Home
3    Relative or Friend's Home       The residence of a relative other than the youth's parent(s) or a friend not related to the
                                     family.
4    Other Adult's Home              The residence of an adult other than a relative or a friend.

5    Other Youth's Home              The residence of a youth other than a relative or a friend.

6    Foster Home                     A temporary residence in which the youth has been legally placed by a social services
                                     agency.
7    Partner/Spouse                  A residence shared with a partner or spouse.

8    Host Home                       The residence of an adult other than a relative or a friend operated as a host home.



    4. ______ In a Residential Program
1    FYSB Transitional Living   FYSB-funded program for older homeless youth ages 16-21 for whom it is not possible to live
                                in a safe environment with a relative and who have no other safe alternative living
     Program                    arrangement.
2    Other Transitional Living       Residential program that provides older homeless youth who have no other safe alternative
                                     living arrangement with the skills they will need to move to independent living.
     Program
3    Group Home                      A structured residential program that provides a homelike environment for those youth unable
                                     to return home, generally a minimum of 3 months and a maximum of 2 years stay.
4    Independent Living              Program funded by the Children's Bureau (U.S. Department of Health and Human Services)
                                     designed to prepare youth in the foster care system to live on their own, independently from
     Program That Is
                                     that system.
     Residential
5    Job Corps                       Residential structured educational/vocational training program aimed at developing skills that
                                     will lead to self-sufficiency.
6    Drug Treatment Center           Drug treatment centers focus on detoxification and substance abuse treatment.

7    Residential Treatment           Residential treatment centers are highly structured, intensive 24-hour treatment programs that
                                     address the full range of needs of young people, including social, educational, mental health,
     Center


    Revised                                                   5                                                       8/8/2011
    HMIS/RHYMIS Entrance Form                                                                  BCC/BCP Programs

                                       and psychological.

8    Educational Institute             A residence at a school, such as a boarding school or college dormitory.

9   Other Agency Residential Another residential program that is run by your agency.
    Program
10 Other Residential            Residential program other than those listed above.
    Program
   5. ______ In a Correctional Institute or Detention Center: Secure facility operated in conjunction with
   the juvenile justice system.

    6. ______In a Mental Hospital: Facility providing treatment for psychiatric illness.

    7. ______ In the Military: In a facility operated by a military organization or a residence approved for
    military personnel.

    8. ______ In Another Living Situation: Other living situation not described above.

    9. ______ Do Not Know: The staff does not have enough information on the youth's
               living situation to correctly choose a response.
    Zip Code of Last Permanent Address ___________                                      Zip data quality
                                                                                        □ Full or Partial Zip Code Recorded
                                                                                        (HUD)
                                                                                        □ Don‘t Know (HUD)
                                                                                        □ Refused (HUD)
    Total # of Household Members
    (in the household that the youth is residing in – count parent, siblings, etc.) _________


    Education Summary
    Currently in School or working on any Degree?
        □ Yes      □ No

    School Status: Choose the code describing the youth's school status. If school was not in session at the
    time of the youth's entrance, this question should pertain to the school year just completed.
       1     Attending School Regularly         The youth is enrolled in an educational program (includes GED) and attends
                                                       classes regularly, without extended absenteeism.
       2      Attending School Irregularly             The youth is enrolled in an educational program (includes GED) and attends
                                                       classes 1-3 days per week on average.
       3      Graduated High School                    The youth has earned a high school diploma.

       4      Obtained GED                             The youth has earned a General Equivalency Diploma.

       5      Dropped Out                              The youth has formally withdrawn from school prior to completing the course of
                                                       study.
       6      Suspended                                The youth has been temporarily removed from school through official school
                                                       action.
       7      Expelled                                 The youth has been permanently removed from school through official school
                                                       action.
       8      Do Not Know                              No information is available on the youth's school status.



    Highest Level of Education Attained
                                                                                                  th
           □ College Degree                  □ Technical School Certification               □ 10 grade
                                                                                                  th
           □ Graduate Degree                 □ No Schooling Completed                       □ 11 grade
                                                                                                  th
           □ Less than High School           □ Nursery School to Fourth Grade               □ 12 grade
                                                 th               th
           □ Some College                    □ 5 grade or 6 grade                           □ High School Diploma
                                                 th               th
           □ Some High School                □ 7 grade or 8 grade                           □ GED


    Revised                                                   6                                                   8/8/2011
     HMIS/RHYMIS Entrance Form                                                             BCC/BCP Programs

                                             th
          □ Some Technical School          □ 9 grade                                    □ Post Secondary School

     Employment Information
     Employment Status: Choose one code describing the youth’s employment status at entrance
         Employed Full-Time or Part-Time  Youth is employed full-time or part-time (includes Military)
         Seasonal/Sporadic                Youth is employed occasionally, with periods of unemployment interspersed
                                                      with employment. This includes summer or holiday-specific employment.
          Not Employed, Looking for Work              Youth is not employed and is actively looking for employment
          Not Employed, in School                     Youth is not employed because he or she is in school.
          No Employed, Unable to Work                 Youth is not employed because he or she is unable to work due to a
                                                      physical disability, a developmental disability, or an illness.
          Not Employed, Not Looking for Work          Youth is not employed and is not looking for employment.
          Do Not Know Employment Status               No information is available on the youth’s employment status at entrance.




     Income and Non-Cash Benefit Information

     Income received from any source in past 30 days? □ Yes             □ No □ Don‘t Know □ Refused

     Total Income Recorded Applies to (check one):
     Youth __________ Household _________        *Total Monthly Income __________________

     Monthly Cash Income Sources — (check all that apply and complete income detail below)
      □ A Veteran‘s Disability Payment            □ Private Disability Insurance
      □ Alimony or Other Spousal Support          □ Retirement Income From Social Security
      □ Child Support                             □ SSDI
      □ Earned Income (Employment)                □ SSI
      □ General Assistance                        □ TANF
      □ No Financial Resources                    □ Unemployment Insurance
      □ Other                                     □ Veteran‘s Pension
      □ Pension From a Former Job                 □ Worker‘s Compensation

     Source ___________________________________                     Monthly Amount: _______________________
     Source ___________________________________                     Monthly Amount: _______________________

     Monthly Non-Cash Income Sources — (check all that apply and complete income detail below)
      □ Supplemental Nutrition Assistance Program (Food Stamps)             □ TANF Child Care Services
      □ MEDICAID                                                            □ TANF Transportation Services
      □ MEDICARE                                                            □ Other TANF-Funded Services
                                                                            □ Section 8, Public Housing or rental
      □ SCHIP                                                               assistance
      □ Special Supplemental Nutrition Program for WIC                      □ Other Source
      □ Veteran‘s Administration (VA) Medical Services

     Source ___________________________________                     Monthly Amount: _______________________

     Annual Income of Household (*Optional)_________________________

     Referral Information

Who referred the youth to the Basic Center Program? Choose one code for the individual or organization
through which the youth was advised about, sent, or directed to the Basic Center Program.




      Revised                                              7                                               8/8/2011
HMIS/RHYMIS Entrance Form                                                                BCC/BCP Programs

1. _______ Self-Referral: The youth came to the agency without any direction from another person or
organization.

2. _______ Individual
    1   Parent/Legal Guardian       The youth's biological parent(s), adoptive parent(s), legal guardian (s), or parent(s) who is
                                    not the youth's legal guardian.
   2     Relative or Friend         A relative other than the youth's parent or guardian or a friend of the young person.

   3     Other Adult or Youth       An adult or youth other than a relative or friend.

   4     Partner/Spouse             The young person's partner or spouse.

   5     Foster Parent:             A foster parent of the youth.

   6     Responsible Adult (not     The residence of an adult other than a relative or a friend operated as a host home
         related) of a Host Home


3. _______ Street Outreach Program
   1    FYSB Street Outreach                A FYSB-funded Street Outreach Program.
        Program
   2    Other Street Outreach               A street outreach program not funded by FYSB.
        Program

4. _______ Temporary Shelter
   1    FYSB Basic Center Program           FYSB-funded program providing core services (shelter, food, clothing, counseling)
                                            to runaway and homeless youth. Basic Center services may be provided in one
                                            central location, such as a group home residence, or in decentralized locations,
                                            such as host homes. Federal guidelines dictate that youth may stay at Basic
                                            Centers for up to 2 weeks using FYSB funding.
   2    Other Youth Emergency               Non-FYSB-funded program providing core services (shelter, food, clothing,
                                            counseling) to runaway and homeless youth. Shelter services may be provided in
        Shelter                             one central location, such as a group home residence, or in decentralized
                                            locations, such as host homes.
   3    Homeless Family Center              A program designed to provide shelter and services to homeless families.

   4    Homeless Shelter                    A program designed to provide shelter and services to homeless individuals.

   5    Safe Place                          An organization designated as a Safe Place as part of the national Project Safe
                                            Place program. Safe Places are business and community buildings that display
                                            the diamond-shaped yellow and black Safe Place logo identifying them as Safe
                                            Place sites and are places in neighborhoods where youth can get immediate help.
                                            Safe Place sites include fast-food restaurants, convenience stores, movie
                                            theaters, and other community facilities such as fire departments, libraries,
                                            YMCAs, and Boys & Girls Clubs. In some cases, buses are designated as mobile
                                            Safe Place sites.
   6    Other Temporary Shelter             A shelter other than those described above that provides a temporary place to
                                            sleep.

5. _______ Residential Program (Operated by Your Agency or Another Agency)

   1    FYSB Transitional Living            FYSB-funded program for older homeless youth ages 16-21 for whom it is not
                                            possible to live in a safe environment with a relative and who have no other safe
        Program                             alternative living arrangement.
   2    Other Transitional Living           Residential program that provides older homeless youth who have no other safe
                                            alternative living arrangement with the skills they will need to move to independent
        Program
                                            living.
   3    Group Home                          A structured residential program that provides a homelike environment for those
                                            youth unable to return home, generally a minimum of 3 months and a maximum of
                                            2 years stay.
   4    Independent Living Program          Program funded by the Children's Bureau (U.S. Department of Health and Human
                                            Services) designed to prepare youth in the foster care system to live on their own,
        That Is Residential
                                            independently from that system.




Revised                                             8                                                  8/8/2011
HMIS/RHYMIS Entrance Form                                                           BCC/BCP Programs

   5    Job Corps                          Residential structured educational/vocational training program aimed at
                                           developing skills that will lead to self-sufficiency.
   6    Drug Treatment Center              Drug treatment centers focus on detoxification and substance abuse treatment.

   7    Residential Treatment Center       Residential treatment centers are highly structured, intensive 24-hour treatment
                                           programs that address the full range of needs of young people, including social,
                                           educational, mental health, and psychological.
   8    Educational Institute              A residence at a school, such as a boarding school or college dormitory.

   9    Other Agency Residential           Another residential program that is run by your agency.
        Program
  10    Other Residential Program          Residential program other than those listed above.



6. _______ Hotline

   1    National Runaway Switchboard       The National Runaway Switchboard.

   2    Other Hotline                      A hotline other than any of the above.



7. _______ Other Agency or Program (Operated by Your Agency or Another Agency

   1    Child Welfare/CPS                  Child Welfare or Child Protective Services.

   2    Independent Living Program         Program funded by the Children's Bureau (U.S. Department of Health and Human
                                           Services) designed to prepare youth in the foster care system to live on their own,
        That Is Nonresidential
                                           independently from that system.
   3    Other Program Operated by          Another nonresidential program that is run by your agency.
        Your Agency
   4    Other Youth Services Agency        Another agency that provides nonresidential services to youth.



8. _______ Juvenile Justice: Agencies such as juvenile courts, correctional institutions, and detention
facilities, or probation and parole workers

9. _______ Law Enforcement/Police: A legally recognized law enforcement body for a town, city, or
county, such as a sheriff's department.

10. _______ Religious Organization: Church, temple, or other organized group espousing the tenets of
a spiritual or religious teaching.

11. _______Mental Hospital: Facility providing treatment for psychiatric illness.

12. _______School: A school.

13. _______Other Organization: Another organization not described above.

14. _______Do Not Know: Insufficient information is available to determine how the youth was referred
to the agency.




Revised                                           9                                                  8/8/2011

				
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