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 Information
First Name*
Middle Name
Last Name*
County of Residence*
How long have you lived in this county?*
Date of Birth*
Date Format: MM slash DD slash YYYY
Social Security Number
Phone #1
Phone #2
Email
Emergency Contact Name
Emergency Contact Phone #
Current Location (Specific)*
Are you a registered sex offender?*
Service Eligibility
How 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?*
How many adults are in your household?*
What is your current gender identity?*
Is anyone in your household transgender?*
Are you or is anyone in your household pregnant?*
Have you or a member of your household served in the US Military, National Guard or Reserve?*
If yes, was it yourself or your household member who served?*
Where did you sleep most frequently in the last 30 days?*
How long have you been in unstable housing?*
Have you or a household member been hospitalized/visited an emergency room 3 or more times in the last 6 months?*
Have you or a household member had interaction with the police 6 or more times in the last 6 months?*
Do 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?*
Do any of your household members have one or more of the above health conditions?*
Have you or a household member been attacked, hurt or threatened since becoming homeless?*
Have you or a household member contemplated, threatened or attempted suicide?*
Have you or a household member experienced domestic violence, sexual assault or human trafficking?*
Are you currently fleeing, or attempting to flee, a domestic violent, sexual assault, human trafficking or stalking situation?*
Do you have a source of income?*
Income 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?*
Field 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