Coordinated Entry Assessment Tool - 211 Connecting Point

1. Getting Started
Date*
Case Worker Name*
Case Worker Phone*
Case Worker Email*
Case Worker Agency*
2. Personal Information
First Name*
Middle Name
Last Name*
SSN
Are you a U.S. Military Veteran?*
Date of Birth
MM slash DD slash YYYY
What is your current gender identity?*
Race*
Ethnicity*
3. Client Contact Information
Phone
Email
Current Address or Location*

Please be specific.
Emergency Contact Name
Emergency Contact Phone #
4. General Residency Information
County of Residence*
How long have you lived in this county?*
Are you a city of Roseville resident?*
- Yes
- No
Are you looking for housing exclusively in Truckee or Tahoe area?*
5. Current Living Situation
What is your current living situation?*
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 & Eligibility
What is your relationship to Head of Household?*
How 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?*
Was it yourself or your household member who served?*
What is their name and date of birth?*
Do you currently have a Housing Voucher/Rental Subsidy?*
What type of Voucher/Rental Subsidy AND what is the expiration date?*
Do you have a source of income?*
Do you receive income for a disability?*
- Yes
- No
What is your current monthly income?*
Are you a CalWORKs participant?*
Do you have any of the following health conditions? Check all that apply.*
- Alcohol Use
- Both Alcohol and Drug Use
- Chronic Health Condition
- Developmental
- Drug Use
- HIV/AIDS
- Mental Health Disorder
- Physical
- None
If "Mental Health Disorder" applies to you, are you a Full Service Partnership Client?*
Have you experienced domestic violence?*
If "Yes," (victim/survivor) are you currently fleeing or attempting to?*
If "Yes," (victim/survivor), when did the experience occur?*
7. Prior Living Situation
Where were you living previously?*
I.e., where did you spend last night? (Or nights previous to tonight)
Where were you living previously?*

I.e., where did you spend last night?
How long were you there?*
What 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?*
How many months have you experienced homelessness over the past three years?*
For the (separate) Vulnerability Assessment Tool form:
Guidance for Provider discretionary points at the end of the Vulnerability Assessment Tool (aka Vulnerability Index or VI) from the Homeless Resource Council of the Sierras (HRCS): “The Nevada-Placer County Vulnerability Assessment Tool is used to rank individuals experiencing homelessness by vulnerability. Through answering the assessment questions, each person is assigned a VI, or vulnerability index, score. The assessment covers many issues but cannot address everything. In the event that a person is experiencing something that increases their vulnerability and is not covered in the assessment, you have the ability to add up to three case management points to their VI score. When adding points, you must consider if the issue is already addressed in the assessment questions and the severity of the issue. While you can add up to three points, one or two points is often more appropriate for the situation. The reason for adding points must be compelling and specific and noted in the person’s HMIS profile.”
Notes:
In the Notes field, please list the reasons for any discretionary points added to the VI so they can be entered into HMIS. You may also note anything else you want the Coordinated Entry HMIS data entry team at Connecting Point to know.
Please submit ALL PAGES of ALL THREE forms to Connecting Point promptly so your Client can be entered into the Homeless Management Information System (HMIS).
How to submit forms to Connecting Point for entry into HMIS: A complete Coordinated Entry packet consists of three forms: • This Coordinated Entry Assessment (CEA) • Client Release of Information (ROI) • Nevada-Placer County Vulnerability Assessment Tool (VI). The ROI and VI will need to be submitted separately via encrypted email or fax. All forms can be scanned into one PDF. Please keep clients separate (i.e., do not scan more than one client’s info. into the same PDF). You may fax forms to Connecting Point at 530-274-5602 (please notify Tiffany and Susan if you are faxing). If you have fax questions call Connecting Point at 530-274-5601. You may email forms encrypted via Barracuda, Virtru, or other secure means. If you have questions or comments, please contact anyone on the Connecting Point CE/HMIS data entry team: Tiffany Lombardi: tiffanyl@connectingpoint.org, 530-277-0033, Susan Sanford: susans@connectingpoint.org, 530-446-0552, Lindsay Gordon: lindsayg@connectingpoint.org, Ulysses Palencia: ulyssesp@connectingpoint.org
Checklist*
- CEA – completed
- ROI – Signed and dated by both Client and Agency Personnel, or state that the Client gave verbal consent and Agency Personnel still signs the form
- VI – Total VI score noted at end of form
- VI – Reason/s for any additional case management points in Notes box above
- VI and ROI - Securely emailed or faxed
Coordinated Entry FAQs and Forms
https://211connectingpoint.org/coordinated-entry/
Case Workers:*
You have now completed the Coordinated Entry Assessment (CEA). Two more documents are required. Please complete a Vulnerability Assessment Tool (VI) and HRCS HMIS Consent for Release of Information (ROI). Once complete, 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

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1. Getting Started

2. Personal Information

3. Client Contact Information

4. General Residency Information

5. Current Living Situation

6. Household Composition & Eligibility

7. Prior Living Situation

For the (separate) Vulnerability Assessment Tool form:

Please submit ALL PAGES of ALL THREE forms to Connecting Point promptly so your Client can be entered into the Homeless Management Information System (HMIS).

Coordinated Entry FAQs and Forms