Coordinated Entry Assessment Tool 1. Getting StartedDate* Case Worker Name* Case Worker Phone*Case Worker Email* Case Worker Agency* 2. Personal InformationFirst Name* Middle Name Last Name* SSN Are you a U.S. Military Veteran?*SelectYesNoDate of Birth* MM slash DD slash YYYY What is your current gender identity?*SelectFemaleMaleTrans FemaleTrans MaleGender Non-ConformingClient refused to answerRace:*SelectAmerican Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteClient Refused to AnswerEthnicity*SelectNon-Hispanic/Non-LatinxHispanic/LatinxClient Doesn't KnowClient Refused3. Client Contact InformationPhoneEmail Current Address or Location* Emergency Contact Name Emergency Contact Phone #4. General Residency InformationCounty of Residence*SelectPlacer CountyNevada CountyHow long have you lived in this county?*SelectLess than 2 weeks2 weeks - 1 month1 month - 3 months3 months - 1 year1 - 3 years3 - 5 years5 years or longerAre you a city of Roseville resident?* Yes No Are you looking for housing exclusively in Truckee or Tahoe area?*SelectYesNo5. Current Living SituationWhat is your current living situation?*SelectPlace not meant for human habitationEmergency shelterFoster care or group homeHospital or other non-psychiatric medical facilityJail, prison, or juvenile detentionLong-term care facility or nursing homeMotel WITH voucherMotel WITHOUT voucherPsychiatric hospital or facilityStaying with familyStaying with friendsSubstance abuse treatment facility/detoxTransitional housing for homeless personsOther (please specify in the following question)What is your current living situation?* Are you going to need to leave your current living situation within 14 days? Yes No Has a subsequent residence been identified? Yes No Do you have resources or support networks to obtain permanent housing? Yes No Have you had a lease or ownership interest in a permanent housing unit in the last 60 Days? Yes No Have you moved 2 or more times in the last 60 days? Yes No 6. Household Composition & EligibilityWhat is your relationship to Head of Household?*SelectSelfChildSpouse or partnerOther relationOther: non relation memberHow many adults are in your household?* How many children are in your household?* Are you an unaccompanied minor? Yes No Have you or a member of your household served in the US Military, National Guard or Reserve?*SelectYesNoWas it yourself or your household member who served?SelectSelfHousehold MemberBoth Self and Household MemberWhat is their name and date of birth? Do you currently have a Housing Voucher/Rental Subsidy?*SelectYesNoWhat type of Voucher/Rental Subsidy AND what is the expiration date? Do you have a source of income?*SelectYesNoClient doesn't knowClient refusedDo you receive income for a disability?* Yes No What is your current monthly income?* Are you a CalWORKs participant?*SelectYesNoN/ADo you have any of the following health conditions? Check all that apply.* Alcohol abuse Both Alcohol and Drug Abuse Chronic Health Condition Developmental Drug Abuse HIV/AIDS Mental Health Physical None If "Mental Health" disability applies, are you a Full Service Partnership Client?*SelectYesNoN/AHave you experienced domestic violence?*SelectYesNoClient doesn't knowClient refusedIf "Yes," (victim/survivor) are you currently fleeing or attempting to?*SelectYesNoIf "Yes," (victim/survivor), when did the experience occur?*SelectWithin last 3 months3-6 months ago6-12 months agoMore than a year agoClient doesn't knowClient refused7. Prior Living SituationWhere were you living previously?*SelectPlace not meant for human habitationEmergency shelterFoster care or group homeHospital or other non-psychiatric medical facilityJail, prison, or juvenile detentionLong-term care facility or nursing homeMotel WITH voucherMotel WITHOUT voucherPsychiatric hospital or facilityStaying with familyStaying with friendsSubstance abuse treatment facility/detoxTransitional housing for homeless personsOther (please specify in the following question)I.e., where did you spend last night?Where were you living previously?* I.e., where did you spend last night?How long were you there?*SelectOne night or less2-6 nights1 week-1 month1 week-3 months3 months-1 year1 year or longerClient doesn't knowClient refusedWhat is an approximate start date for your most recent experience of being homeless? MM slash DD slash YYYY How many times have you been homeless in the past three years including today?*SelectOnceTwiceThree timesFour or more timesClient doesn't knowClient refusedHow many months have you experienced homelessness over the past three years?*Select1 (this is my first month being homeless)23456789101112More than 12 monthsClient doesn't knowClient refusedNotes:Coordinated Entry FAQs and Formshttps://211connectingpoint.org/coordinated-entry/Case Workers:*You have now completed the Coordinated Entry Assessment (CEA). Two more documents are needed. Please complete a Vulnerability Assessment Tool (VI) and HRCS HMIS Consent for Release of Information (ROI). Once complete, please securely email both documents to susans@connectingpoint.org, tiffanyl@connectingpoint.org, and lindsayg@connectingpoint.org. Upon receipt of all three completed forms, the client will be added to the HMIS database. I will email VI and ROI I will fax or drop off paper copies of VI and ROI Other
