Assessment Tool – Initial Screening - State of Oregon



Assessment Tool – Initial ScreeningHOUSEHOLD NameQuestions about Homeless StatusTell me about your housing situation: _______________________________________________________________________________Does any program help pay for some or all of your rent? FORMCHECKBOX Yes FORMCHECKBOX NoAgency/program providing housing subsidy: ___________________________________________Where did you stay last night? ______________________________________________________How long have you stayed there? ____________________________________________________Is it safe to stay there? FORMCHECKBOX Yes FORMCHECKBOX NoCan you continue to stay there temporarily? FORMCHECKBOX Yes FORMCHECKBOX NoIf you can stay there, how long can you stay? __________________________________________What would it take for you to continue to stay there? __________________________________________________________________________________________________________________When is the last time you had a permanent place to stay (where you stayed for 90 days or more, that was not a shelter)? ___________________________________________________________Are you about to lose your housing? FORMCHECKBOX Yes FORMCHECKBOX NoDate client has to leave: ___________________________________________________________Do you have a lease or legal rights to the property? FORMCHECKBOX Yes FORMCHECKBOX NoAre you being evicted? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have an eviction notice? FORMCHECKBOX Yes FORMCHECKBOX NoIs the eviction reconcilable? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have a court date? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is the court date? ____________________________________________________________What will happen to your HH if you don’t get help from a housing program? _______________________________________________________________________________Is there plan for finding or staying in housing? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is that plan? ________________________________________________________________Is there a plan of action for paying on-going expenses? FORMCHECKBOX Yes FORMCHECKBOX NoWhat is that plan? ________________________________________________________________Question about Potential Barriers to HousingDo you have pets? FORMCHECKBOX Yes FORMCHECKBOX NoDoes anyone in the HH have a companion animal? FORMCHECKBOX Yes FORMCHECKBOX NoDoes anyone in the HH have a service animal? FORMCHECKBOX Yes FORMCHECKBOX NoDoes client owe money to any housing programs or previous landlords for back rent or damages? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, to whom is the money owed? _________________________________________________If yes, total of housing arrearages: ___________________________________________________Does client owe money to any local utility companies? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, to whom is the money owed? _________________________________________________If yes, total utility arrearages owed: __________________________________________________Is anyone in the HH pregnant? FORMCHECKBOX Yes FORMCHECKBOX NoExpected due date: _______________________________________________________________First name of pregnant member of HH: _______________________________________________Are there any restrictions on where any HH member can live? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is client restricted from having social contact with minors? FORMCHECKBOX Yes FORMCHECKBOX NoFirst name of member who has restriction on where they can live: _________________________Do you have no rental history? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have previous eviction(s)? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have a sporadic employment history? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have no or poor credit history? FORMCHECKBOX Yes FORMCHECKBOX NoWhat type of debts do you have that created a poor credit history? __________________________Do you still have these debts? FORMCHECKBOX Yes FORMCHECKBOX NoDo you (or any family member) have a recent history of substance abuse or actively using drugs or alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoDo you (or any family member) have a recent criminal history? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have an adult or child with mild to severe behavioral problems? FORMCHECKBOX Yes FORMCHECKBOX NoDo you (or any family member) have a history of abuse and/or battery, but abuser not in the unit? FORMCHECKBOX Yes FORMCHECKBOX NoDoes someone in your HH have a disabling condition? FORMCHECKBOX Yes FORMCHECKBOX NoDoes any in the HH have a disabling condition that limits mobility? FORMCHECKBOX Yes FORMCHECKBOX NoFirst name of HH member with limited mobility: ________________________________________Does any in the HH have a disabling condition that limits their ability to work? FORMCHECKBOX Yes FORMCHECKBOX NoFirst name of HH member whose disability limits their ability to work: ______________________Questions about Support SystemHas anyone been helping you lately? FORMCHECKBOX Yes FORMCHECKBOX NoName, relationship, organization, phone #, type of help offered: __________________________________________________________________________________If anyone has been helping you, might you be able to stay with them temporarily? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name & Contact Info: __________________________________________________________________________________Do you have any Case Manager/Case Worker in the community? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, Name, Organization, Contact Info: __________________________________________________________________________________Questions about Income/Resources:Have there been any recent significant changes in HH income? FORMCHECKBOX Yes FORMCHECKBOX NoWhat changes have there been? _______________________________________________________________________________Are you expecting to receive any money that could be used to stabilize your housing situation? FORMCHECKBOX Yes FORMCHECKBOX NoWhat would that be? ______________________________________________________________Have there been any recent significant changes to HH expenses? FORMCHECKBOX Yes FORMCHECKBOX NoWhat changes have there been? _____________________________________________________Do you have a vehicle? FORMCHECKBOX Yes FORMCHECKBOX NoHow many vehicles do you have and for what purpose? __________________________________Do you have an RV with 4 wheels? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have anything that could be sold or converted into cash? (assets) FORMCHECKBOX Yes FORMCHECKBOX NoWhat would that be and how much cash would you get? __________________________________________________________________________________Other Areas of ConcernAre there any other areas of concerns that you may have? Please describe how we may help you: FORMCHECKBOX Child Abuse/Neglect: ___________________________________________________________________ FORMCHECKBOX Disability: ____________________________________________________________________________ FORMCHECKBOX Domestic Violence: ____________________________________________________________________ FORMCHECKBOX Education: ___________________________________________________________________________ FORMCHECKBOX Employment: _________________________________________________________________________ FORMCHECKBOX Food: _______________________________________________________________________________ FORMCHECKBOX Health: ______________________________________________________________________________ FORMCHECKBOX Lack of Parenting Skills: _________________________________________________________________ FORMCHECKBOX Legal: _______________________________________________________________________________ FORMCHECKBOX Life Skills: ____________________________________________________________________________ FORMCHECKBOX Mental Health: ________________________________________________________________________ FORMCHECKBOX Relationship Issues: ____________________________________________________________________ FORMCHECKBOX Safety: ______________________________________________________________________________ FORMCHECKBOX Stability: _____________________________________________________________________________ FORMCHECKBOX Substance Abuse: ______________________________________________________________________ FORMCHECKBOX Other: _______________________________________________________________________________ FORMCHECKBOX Other: _______________________________________________________________________________ FORMCHECKBOX Other: _______________________________________________________________________________ FORMCHECKBOX Other: _______________________________________________________________________________Based on items checked above, you may wish to complete a Strengths and Needs Assessment for specific areas:Physical Health: (basic, health, health history, strengths, limitations, handicapping conditions, developmental history, physical capability, immunizations, Doctor’s name and phone number, contagions, medications and dosages)Notes:Strengths:Needs:Mental Health: (mental status, behavior, affect, counseling needs, psychiatric history, psychotropic medication, suicidal behavior, aggressive behavior, counselor/therapist name and phone)Notes:Strengths:Needs:Drugs/Alcohol/Addictions: (history, treatment attempts, current status, interviewer’s observations, other addictive behaviors)Notes:Strengths:Needs:Parenting: (number/ages of children, child welfare involvement, children not living with client, status of children out of household, visitation with children, skill level, understanding of child development, stress factors)Notes:Strengths:Needs:Family/Social: (size, composition, history, type housing, support system (names), relationship history, abuse history, legal history, racial/ethnic/cultural background)Notes:Strengths:Needs:Educational: (highest grade, language capabilities, primary language, school history, academic skills, areas of difficulty, educational goals)Notes:Strengths:Needs:Work/Employment: (work history, current employment status, TANF, family income, vocational goals and interests)Currently employed? FORMCHECKBOX Yes FORMCHECKBOX NoIf no, wage per hour that you would normally make? ____________________________________________If yes, is this FORMCHECKBOX Permanent FORMCHECKBOX Part-time FORMCHECKBOX Temporary FORMCHECKBOX Seasonal work?Are you currently looking for work? FORMCHECKBOX Yes FORMCHECKBOX NoAre you currently unable to work? FORMCHECKBOX Yes FORMCHECKBOX NoNotes:Strengths:Needs:Legal: (convictions, pending court cases, restraining orders, parole officer, warrants, felonies on record)Notes:Strengths:Needs:Identification/Paperwork:Do you, or any other member, need assistance in obtaining any of the following Identification documents? FORMCHECKBOX Social Security Card – who? _____________________________________________________________ FORMCHECKBOX Birth Certificate – who? ________________________________________________________________ FORMCHECKBOX State ID – who? _______________________________________________________________________ FORMCHECKBOX Driver’s License – who? _________________________________________________________________Notes:Strengths:Needs:Other Issues:Notes:Strengths:Needs:Intake Worker Name (print)Intake Worker Name (signature)Date ................
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