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Includes structured fields for name, SSN and related data-quality indicators when full information is not collected. Captures birth date quality, race/ethnicity selections, gender options, pronouns, veteran-related details, barriers/special needs for multiple conditions, and health insurance coverage selections. Guides assessors on when to continue pages based on age.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/household-member-ces-assessment-form/306975/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/household-member-ces-assessment-form/306975.png","ImageObject",442,249,{"name":88,"@type":89},"วิน","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-21","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information does the form collect for each household member?","Question",{"text":109,"@type":110},"The form collects household member identifying information (including name and SSN with data-quality fields), basic demographics, contact details, universal assessment fields, barriers/special needs, and health insurance coverage.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form record cases where the client does not provide full details?",{"text":114,"@type":110},"It includes data-quality fields for items like name, SSN, and date of birth, allowing selection of options such as “client doesn’t know,” “client prefers not to answer,” or “data not collected.”",{"name":116,"@type":107,"acceptedAnswer":117},"When should the assessor complete the veteran assessment section?",{"text":118,"@type":110},"If the household member is age 18 or older and the client identifies as a veteran, the assessor continues with the veteran assessment section; otherwise, it is skipped according to the form instructions.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},306975,1790618037,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":73},2336475104736,"https://ap-avatar.wpscdn.com/avatar/22000c4c5e0e5b17e70?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786591360781797222","INSTRUCTIONS: Complete one fully copy of this form for each additional household member. Paper forms should be stored in the client’s file at the Access Point per CoC regulations. Instructions for the assessor appear throughout the document in orange.  \nFAMILY MEMBER INFORMATION: Complete the client's identifying information. Name and SSN have associated data quality fields. Data quality fields are used to indicate the reason full information wasn't collected. Name and social security number data quality fields allow users to indicate when a client doesn't know or refuses to provide information. If the required data is collected then ClientTrack automatically records that full data quality was met.  \nAssessment date:   First Name* :    \nMiddle Name:   Last Name* :    \nSuffix:   Name Quality* : Full Name Reported  \nSSN:    \nSSN Quality* : ☐ Full SSN ☐ Client Doesn’t Know ☐ Client Prefers Not to Answer  \n☐ Data Not Collected  \nBASIC CLIENT DEMOGRAPHICS:  \nBirth Date:   Client Age:    \nDate of birth quality * : Full DOB Reported  \nAdditional Race and Ethnicity Detail:    \nRace (choose all that apply) * :  \n☐ American Indian, Alaska Native, or Indigenous  \n☐ Asian or Asian American ☐ Middle Eastern or North African ☐ Black, African American, or African ☐ Native Hawaiian or Pacific Islander  \n☐ Hispanic/Latina/e/o  \n☐ White  \n☐ Client doesn’t know ☐ Client prefers not to answer ☐ Data not collecte  \nGender (choose all that apply)* :  \n☐ Woman (Girl, if child)  \n☐ Man (Boy, if child)  \n☐ Culturally Specific Identity (e.g., Two-Spirit)☐ Transgender  \n☐ Non-Binary  \n☐ Questioning  \n☐ Different Identity  \n☐ Client doesn’t know ☐ Client prefers not to answer ☐ Data not collected  \nPronouns (if given):   Sexual Orientation:    \nThe following two questions are only required for persons age 18+:  \nVeteran Status* :   Marital Status:    \nCONTACT INFORMATION:  \nAddress:    \nCity, State, Zip Code:    \nEmail:   Primary Phone:    \nWork Phone:   Msg Phone:    \nUNIVERSAL DATA ASSESSMENT:  \nAssessment Date* :   Assessor Name* :    \nDisabling Condition* : ☐ Yes ☐ No ☐ Client Doesn’t Know  \n☐ Client Prefers Not to Answer ☐ Data Not Collected  \nIf yes, complete the following chart. Otherwise, skip to Health Insurance section.  \nBARRIERS/SPECIAL NEEDS  \n\n| ALCOHOL ABUSE |  |  |\n| --- | --- | --- |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| CHRONIC HEALTH CONDITION (defined as a diagnosed condition that is more than 3 months in duration and is either not curable or has residual effects that limit daily living and require adaptation in function or special assistance) |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| DEVELOPMENTAL DISABILITY |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| DRUG ABUSE |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| HIV/AIDS |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n\n\n| MENTAL HEALTH |  |  |\n| --- | --- | --- |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| OTHER |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| PHYSICAL DISABILITY |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| FELONY CONVICTION |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n| HISTORY OF FOSTER CARE |  |  |\n| Barrier present? ☐ Yes ☐No |  |  |\n| If yes: | Condition is indefinite?\u003Cbr>☐ Yes ☐No | Explanation: |\n\nHEALTH INSURANCE (choose all that apply):  \n☐ Private  \n☐ Private- Individual ☐ Private – Employer  \n☐ Health insurance obtained through COBRA ☐ Medicare  \n☐ Medicaid  \n☐ State ","cbCaibRGicVY1v0D","https://ap.wps.com/l/cbCaibRGicVY1v0D","pdf",280783,6,"English","# Family Member Information\n# Basic Client Demographics\n# Contact Information\n# Universal Data Assessment\n## Barriers/Special Needs\n# Health Insurance\n# Veteran Assessment\n## Military Service Dates","[{\"question\":\"What information does the form collect for each household member?\",\"answer\":\"The form collects household member identifying information (including name and SSN with data-quality fields), basic demographics, contact details, universal assessment fields, barriers/special needs, and health insurance coverage.\"},{\"question\":\"How does the form record cases where the client does not provide full details?\",\"answer\":\"It includes data-quality fields for items like name, SSN, and date of birth, allowing selection of options such as “client doesn’t know,” “client prefers not to answer,” or “data not collected.”\"},{\"question\":\"When should the assessor complete the veteran assessment section?\",\"answer\":\"If the household member is age 18 or older and the client identifies as a veteran, the assessor continues with the veteran assessment section; otherwise, it is skipped according to the form instructions.\"}]","Household Member CES Assessment Form | PDF",1789842761]