Coordinated Entry Tool Posted on October 4, 2019December 18, 2019 CE Tool with VI for outreach workers Field Agent Name*Agency*Field Agent Phone*Personal InformationFirst Name*Middle NameLast Name*County of Residence*Placer CountyNevada CountyHow long have you lived in this county?*Less than 2 weeks2 weeks - 1 month1 month - 3 months3 months - 1 year1 - 3 years3 - 5 years5 years or longerDate of Birth* Date Format: MM slash DD slash YYYY Social Security NumberPhone #1Phone #2Email Emergency Contact NameEmergency Contact Phone #Current Location (Specific)*Are you a registered sex offender?*YesNoService EligibilityHow many people are in your household?*How many of these people are children under age 18?*How many children under age 5?*If there are children under age 18 in your household, are you currently a CalWORKs participant?*YesNoN/AHow many adults are in your household?*What is your current gender identity?*MaleFemaleTrans MaleTrans FemaleGender Non-ConformingDon't KnowDecline to StateIs anyone in your household transgender?*YesNoDecline to StateAre you or is anyone in your household pregnant?*YesNoHave you or a member of your household served in the US Military, National Guard or Reserve?*YesNoIf yes, was it yourself or your household member who served?*SelfHousehold MemberN/AWhere did you sleep most frequently in the last 30 days?*Emergency ShelterHospital/Medical facilityLong-term care facility/Nursing homeSubstance abuse treatment facility/DetoxFoster care/Group homeJail, prison or juvenile detentionPlace not meant for human habitation/VehicleTransitional HousingOtherHow long have you been in unstable housing?*Less than 1 year1 - 3 years3 - 5 years5 + yearsHave you or a household member been hospitalized/visited an emergency room 3 or more times in the last 6 months?*YesNoHave you or a household member had interaction with the police 6 or more times in the last 6 months?*YesNoDo you have any of the following health conditions?* Mental Health Disability Substance Abuse Alcohol Abuse Physical or sensory disability Developmental disability Chronic conditions HIV/AIDS If you selected "Mental Health Disability", are you a Full Service Partnership Client?*YesNoN/ADo any of your household members have one or more of the above health conditions?*YesNoN/AHave you or a household member been attacked, hurt or threatened since becoming homeless?*YesNoHave you or a household member contemplated, threatened or attempted suicide?*YesNoHave you or a household member experienced domestic violence, sexual assault or human trafficking?*YesNoAre you currently fleeing, or attempting to flee, a domestic violent, sexual assault, human trafficking or stalking situation?*YesNoDo you have a source of income?*YesNoIncome source type(s):* SSI SSDI SDI Government Aid Employment Pension Investment Retirement Child support Help from family/friends None What is you household income?*Is this amount monthly or annual?*MonthlyAnnualN/AField Agents/Outreach Workers:*Please fax the HRCS HMIS Consent for Release of Information with the clients signature to 530-274-5606. Upon receipt of the Consent form, the client will be added to the HMIS database. I have already faxed HMIS Consent I will be faxing HMIS Consent later
