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Yes No  \nLegal FirstName:   Middle Name:    \nLegal LastName:   Suffix:    \nProject Name:   Project Entry Date: / /   \nCase Manager:   Date of Assessment:  / /   \nIncome – Cash Sources:  \n\n| Income Source (Check all that apply): | Stated Income: | Pay Interval: |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n|  |  | Weekly | Every Other\u003Cbr>Week | Twice\u003Cbr>A Month | Monthly | Quarterly | Yearly |\n| No financial resources |  |  |  |  |  |  |  |\n| Earned Income |  |  |  |  |  |  |  |\n| Unemployment Insurance |  |  |  |  |  |  |  |\n| Supplemental Security Income (SSI) |  |  |  |  |  |  |  |\n| Social Security Disability (SSDI) |  |  |  |  |  |  |  |\n| VA Service-Connected Disability Compensation |  |  |  |  |  |  |  |\n| Private Disability Insurance |  |  |  |  |  |  |  |\n| Workers Compensation |  |  |  |  |  |  |  |\n| General Assistance (GA orGR) |  |  |  |  |  |  |  |\n| Retirement Income from Social Security |  |  |  |  |  |  |  |\n| VA Non-Service-Connected Disability Pension |  |  |  |  |  |  |  |\n| Pension from a former job |  |  |  |  |  |  |  |\n| Child Support |  |  |  |  |  |  |  |\n| Alimony or other spousal support |  |  |  |  |  |  |  |\n| Other Source |  |  |  |  |  |  |  |\n| TANF |  |  |  |  |  |  |  |\n| Client Doesn’t Know |  |  |  |  |  |  |  |\n| Client Refused |  |  |  |  |  |  |  |\n| Data not Collected |  |  |  |  |  |  |  |\n\nIncome – Non-Cash Benefits:  \n\n| Non-Cash Benefits (Check all that apply): |  |  |  |\n| --- | --- | --- | --- |\n| None\u003Cbr>Food Stamps (CalFresh) Amount:  \u003Cbr>WIC | Client Doesn’t Know\u003Cbr>CalWorks Child Care CalWorks Transportation\u003Cbr>Other CalWorks-Funded Services | Client Refused\u003Cbr>Temporary Rental Assistance Section 8 or Rental Assistance Other | Data not Collected\u003Cbr>Medically Needy Amount: |\n\n\n| Health Insurance (Check all that apply): |  |  |  |\n| --- | --- | --- | --- |\n| No Health Insurance | Client Doesn’t Know | Client Refused | Data not Collected VA |\n| Medi-Cal | MEDICARE | State Children’s Health Ins. | Medical Services |\n| Employer Provided Health Ins. | COBRA Health Ins. | Private Health Ins. | Indian Health Services |\n| Other |  |  | Program |\n\nCompliance Date: 10.01.2016 HUD Data Standards Manual  \nPage 1  \nAssessment Questions – All clients, required questions are shaded  \n\n| Question | Check One Answer |  | Comments |\n| --- | --- | --- | --- |\n| 1. Is this an update or annual assessment? | Project Update\u003Cbr>Project Annual Assessment |  |  |\n| 2. Do you have a physical disability? | No Yes\u003Cbr>Client Doesn’t Know Client Refused Data not Collected |  |  |\n| 2a. Do you expect this to be of long–continued and indefinite duration AND substantially impair your ability to live independently?\u003Cbr>(Required if question 2 is ‘Yes’) | No\u003Cbr>Yes | Client Doesn’t Know\u003Cbr>Client Refused\u003Cbr>Data not Collected |  |\n| 2b. Do you have documentation of the disability and severity on file?\u003Cbr>(Required if question 2 is ‘Yes’) | No Yes |  |  |\n| 2c. Are you currently receiving services/treatment for this disability?\u003Cbr>(Required if question 2 is ‘Yes’) | No\u003Cbr>Yes | Client Doesn’t Know\u003Cbr>Client Refused\u003Cbr>Data not Collected |  |\n| 3. Do you have a developmental disability? | No Yes\u003Cbr>Client Doesn’t Know Client Refused Data not Collected |  |  |\n| 3a. Do you expect this to be of long–continued and indefinite duration AND substantially impair your ability to live independently?\u003Cbr>(Required if question 3 is ‘Yes’) | No\u003Cbr>Yes | Client Doesn’t Know\u003Cbr>Client Refused\u003Cbr>Data not Collected |  |\n| 3b. Do you have documentation of the disability and severity on file?\u003Cbr>(Required if question 3 is ‘Yes’) | No Yes |  |  |\n| 3c. Are you currently receiving services/treatment for this disability?\u003Cbr>(Required if question 3 is ‘Yes’) | No\u003Cbr>Yes | Client Doesn’t Know\u003Cbr>Client Refused\u003Cbr>Data not Collected |  |\n| 4. Do you have a chronic health condition? | No Yes\u003Cbr>Client Doesn’t Know Client Refused Data not Collected |  ","cbCaitYm28U2cKoy","https://ap.wps.com/l/cbCaitYm28U2cKoy","pdf",131852,7,"English","# Name/Identification and Contact Information\n## Income - Cash Sources\n## Income - Non-Cash Benefits\n## Health Insurance\n## Assessment Questions - All Clients, Required Questions Shaded","[{\"question\":\"What information does the HMIS consent form collect before the assessment questions?\",\"answer\":\"It gathers client name/identification fields, project name, project entry date, case manager, and assessment date, along with a signed consent confirmation.\"},{\"question\":\"How are cash income sources and pay intervals recorded?\",\"answer\":\"Income sources are selected via check-boxes and paired with a stated income amount and a chosen pay interval such as weekly, monthly, quarterly, or yearly.\"},{\"question\":\"What disability and health condition topics are covered in the required assessment questions?\",\"answer\":\"The questionnaire asks whether the client has physical, developmental, or chronic health conditions, whether the client has AIDS or tested positive for HIV, and whether the client has a current mental health problem, including follow-up items when applicable.\"}]","HMIS Consent Form - Project Assessment Questions | PDF",1789198699]