PATH Data Collection Form for ServicePoint



-381019050Interim Review Date: _____/_____/_______ Project Name:__________________________________________ ServicePointClient ID ________________________ Is Client the Head of Household? ? Yes ? No If Client is Not Head of Household, Head of Household Name: _____________________________________________ 00Interim Review Date: _____/_____/_______ Project Name:__________________________________________ ServicePointClient ID ________________________ Is Client the Head of Household? ? Yes ? No If Client is Not Head of Household, Head of Household Name: _____________________________________________ First Name: MI: Last Name: _______________________________ Suffix: ___________VI-SPDAT Date: ______/_______/_____________ VI-SPDAT Type: ? Individual ? Family ? Teen VI-SPDAT Score: _________ Housing Stability Plan Completed: ?Yes ?No Housing Stability Plan Date: ______/_______/_____________Client Location: ? Maine CoC – ME-500 ? Portland CoC – ME-502Receiving Income from any source? ?Yes ?No ?Client Doesn’t Know ?Client Refused ?Data Not CollectedReceiving IncomeSource of Income (Check all that apply)Income Amount??Yes ?No Earned Income$??Yes ?NoUnemployment Insurance $??Yes ?No Supplemental Security Income (SSI) $??Yes ?NoSocial Security Disability Income (SSDI) $??Yes ?NoVA Service Connected Disability Compensation $??Yes ?NoPrivate Disability Insurance$??Yes ?NoWorker’s Compensation$??Yes ?No Temporary Assistance for Needy Families (TANF)$??Yes ?NoGeneral Assistance $??Yes ?NoRetirement Income From Social Security$??Yes ?NoVA Non-Service Connected Disability Pension$??Yes ?NoPension or Retirement Income from Another Job$??Yes ?NoChild Support$??Yes ?NoAlimony or Other Spousal Support $??Yes ?NoOther – Specify Source _____________________$Receiving Non-Cash Benefit from any source? ?Yes ?No ?Client Doesn’t Know ?Client Refused ?Data Not CollectedReceiving BenefitSource of Non-Cash Benefit (Check all that apply)Benefit Amount (when applicable)??Yes ?NoSupplemental Nutrition Assistance Program (SNAP – Food Stamps) $??Yes ?NoSpecial Supplemental Nutrition Program for Women, Infants and Children (WIC)$??Yes ?NoTANF Child Care services$??Yes ?NoTANF transportation services$Benefit Information (cont.)??Yes ?NoOther TANF-funded services$??Yes ?NoSection 8, public housing, or other ongoing rental assistance$??Yes ?NoTemporary Rental Assistance$??Yes ?NoOther Source – Specify Source _____________________________________$Is Client Covered by Health Insurance? ?Yes ?No ?Client Doesn’t Know ?Client Refused ?Data Not CollectedCoveredHealth Insurance Type (Check all that apply)??Yes ?NoMEDICAID??Yes ?NoMEDICARE ??Yes ?No State Children’s Health Insurance Program ??Yes ?NoVeteran’s Administration (VA) Medical Services ??Yes ?NoEmployer-Provided Health Insurance ??Yes ?NoHealth Insurance obtained through COBRA??Yes ?NoState Health Insurance for Adults??Yes ?NoPrivate Pay Health Insurance Do you have a disability of long duration? ?Yes ?No ?Client Doesn’t Know ?Client Refused ?Data Not CollectedDisability TypeExpected to be of long-continued and indefinite duration and substantially impairs ability to live independentlyDocumentation of the disability and severity on file? Currently Receiving Treatment or Services?Physical?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoDevelopmental????Yes ?No ?Client Doesn’t Know ?Client Refused????Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoChronic Health Condition?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoHIV/AIDS?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoMental Health Problem?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoAlcohol Abuse?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoDisability Information (cont.)Drug Abuse?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoBoth Alcohol and Drug Abuse?Yes ?No ?Client Doesn’t Know ?Client Refused?Yes ?No ?Client Doesn’t Know ?Client Refused??Yes ?No??Yes ?NoHas the client ever been a victim of domestic violence? ?Yes ?No ?Client Doesn’t Know ?Client Refused ?Data Not CollectedIf yes, how long ago? ? Within the past three months ? Three to six months ago ? From six to twelve months ago ? More than a year ago ? Client Doesn't know ? Client RefusedIf yes, are you currently fleeing? ?Yes ?No ? Client Doesn’t Know?? Client Refused?? Data Not Collected ................
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