Coordinated Entry Assessment Tool - 211 Connecting Point

Please review the Coordinated Entry FAQs document for detailed information about submitting CE to Connecting Point for entry into HMIS. This form was updated 12/02/22. Link to FAQ document is near the bottom of this web page: https://211connectingpoint.org/coordinated-entry/
1. Getting Started
Date*
Case Worker Name*
Case Worker Phone*
Case Worker Email*
Case Worker Agency*
Assessment Location*
- Nevada County
- Placer County
How is/was this CEA intake completed with the client?*
- Phone
- Virtual
- In Person
2. Personal Information
First Name*
Middle Name
Last Name*
Alias (If applicable)
Date of Birth
MM slash DD slash YYYY
If client prefers not to provide date of birth, type CLIENT PREFERS NOT TO ANSWER below
SSN (or type CLIENT PREFERS NOT TO ANSWER)
Are you a U.S. Military Veteran?*
What are your pronouns?
If other pronouns:
What is your preferred language?
What is your current gender identity?*
If different identity:
Do you or someone in your household identify as LGBTQ+?*
Race*
Ethnicity
3. 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?*
4. Client Contact Information
Phone
Email
Current Address or Location (Please be specific. Where is client staying? If outside, put street name.)*
Emergency Contact Name
Emergency Contact Phone #
5. Current Living Situation
What is your current living situation?*
If "Subsidy" or "Voucher" please select the type of subsidy
If "Other" please specify*
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
If you are temporarily or permanently housed, what is your current status (eviction notice, housing unstable, staying with someone but need to leave soon, seeking housing voucher, rental assistance, etc)?
6. Household Composition
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 (mm/dd/yyyy)?*
Do you have a source of income?*
Do you receive income for a disability?*
- Yes
- No
What is your current monthly income?*

(Must be one number/amount – cannot be a range; no words)
Are you a CalWORKs participant?*
Do you have any of the following health conditions? Check all that apply.*
- Alcohol Use Disorder
- Both Alcohol and Drug Use Disorder
- Chronic Health Condition
- Developmental
- Drug Use Disorder
- HIV/AIDS
- Mental Health Disorder
- Physical
- None
If "Mental Health Disorder" applies to you, are you a Full Service Partnership Client?*
Are you a Domestic Violence Victim/Survivor?*
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 did you spend last night?*
If "Subsidy" or "Voucher" please select the type of subsidy
If "Other" please specify*
How long were you staying 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?*
(Total number of months)
IMPORTANT NOTE TO CASE WORKERS:*
By clicking SUBMIT below you will securely submit the completed the Coordinated Entry Assessment (CEA) form to Connecting Point. ONE MORE DOCUMENT IS REQUIRED. Please complete a Vulnerability Assessment Tool (aka Vulnerability Index or VI). Find it at the bottom of this page: https://211connectingpoint.org/coordinated-entry/. When complete, choose one of the following options to submit BOTH PAGES of the VI document: • Upload VI document into “File Attachments” section of Client Profile tab in HMIS. This is the preferred method for keeping client data secure. Add the Vulnerability Score and notes for any discretionary case management points awarded. • Securely email VI to ceintake@connectingpoint.org encrypting with Virtru, Barracuda or other approved encryption software • Fax VI to Connecting Point at 530-274-5602 • BEFORE FAXING: YOU MUST CALL 530-274-5601 to ensure someone is ready to receive the fax immediately so that client information is protected, OR email ceintake@connectingpoint.org
- I will upload VI into HMIS and add Vulnerability Score and reason/s for any discretionary point/s
- I will SECURELY email VI to ceintake@connectingpoint.org
- I will fax VI to 530-274-5602. YOU MUST CALL 530-274-5601 OR EMAIL ceintake@connectingpoint.org to say a fax is coming
Notify Connecting Point*
- I will email ceintake@connectingpoint.org to say I have submitted this form.
For (separate) Vulnerability Assessment Tool form:
Guidance for Case Workers’ 3 additional discretionary points which may be awarded on a client’s Vulnerability Assessment Tool 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.”
VI SCORE NOTES – Case workers, please list reasons for any discretionary points added to the VI.
Please remember to submit ALL PAGES of BOTH forms to Connecting Point. Thank you!
Reminder ~ Find Coordinated Entry FAQs and Forms here:
https://211connectingpoint.org/coordinated-entry

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Please review the Coordinated Entry FAQs document for detailed information about submitting CE to Connecting Point for entry into HMIS. This form was updated 12/02/22. Link to FAQ document is near the bottom of this web page: https://211connectingpoint.org/coordinated-entry/

1. Getting Started

2. Personal Information

3. General Residency Information

4. Client Contact Information

5. Current Living Situation

6. Household Composition

7. Prior Living Situation

For (separate) Vulnerability Assessment Tool form:

Please remember to submit ALL PAGES of BOTH forms to Connecting Point. Thank you!

Reminder ~ Find Coordinated Entry FAQs and Forms here: