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STABLE FAMILIES Assessment/Enrollment Family Name:______________________________________________________ Date of Enrollment: _________________________________________________ What are your top three housing concerns? 1._____________________________________________________________________________ 2._____________________________________________________________________________ 3._____________________________________________________________________________ Have you had those concerns before? (circle) Yes No If yes, what did you do in the past when you had those concerns? _________________________________________________________________________ _________________________________________________________________________ If no, what did you do to avoid getting into those housing issues? _________________________________________________________________________ _________________________________________________________________________ On scale from 1-10 where would you rate your progress towards resolving these concerns? (circle) 1 2 3 4 5 6 7 8 9 10 Little or no progress

Some Progress

Great Progress

What kept you from rating yourself lower? _____________________________________________________________________________ _____________________________________________________________________________ Where do you want to be? _____________________________________________________________________________ _____________________________________________________________________________ What would that look like for you? _____________________________________________________________________________ _____________________________________________________________________________ Assessment Page 1

STABLE FAMILIES Assessment/Enrollment

Please list 2 emergency contacts that will always know how to reach you. Name __________________________ __________________________

Relationship ___________________ ___________________

Number _________________ _________________

Disability Determination: Are you disabled? For this definition a disabling condition means: (1) A disability as defined in Section of 223 of the Social Security Act; (2) a physical, mental, or emotional impairment which is (a) expected to be of long-continued and indefinite duration, (b) substantially impedes an individual’s ability to live independently, and as of such a nature that such ability could be improved by more suitable housing condition; (3) a developmental disability as defined in section 102 of Developmental Disabilities Assistance and Bill of Rights Act; (4) the disease of acquired immunodeficiency syndrome or any conditions arising from the etiological agency for acquired immunodeficiency syndrome; or (5) a diagnosable substance abuse disorder. (circle) Yes No Don’t Know Refused If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle) Yes

No

Currently receiving services or treatment for this condition? (circle) Yes No Don’t Know

Refused

Assessment Page 2

STABLE FAMILIES Assessment/Enrollment PLEASE USE THESE CODES FOR THE QUESTIONS THAT FOLLOW Race Codes: W— White AA—Black or African American AS— Asian HP— Native Hawaiian or Pacific Islander or other Pacific Islander

AI— American Indian

AN— Alaska Native

Relationship Codes: son, daughter, step-son, step-daughter, grandson, granddaughter, wife, husband, brother, sister, mother, father, grandmother, grandfather, significant other, other relative, other non-relative, unknown Gender Codes: F—Female -Other DK—Don’t know

M—Male TMF—Transgendered Male to Female R—Refused

Ethnicity: NN—Non Hispanic/Non Latino H—Hispanic/Latino

TFM—Transgendered Female to Male

DK—Don’t know

O

R—Refused

Highest Education Level Completed: no schooling, nursery school to 4th grade, 4th grade to 6th grade, 7th to 8th grade, 9th grade, 10th grade, 11th grade, 12th grade no diploma, high school diploma, GED, post-secondary school, don't know, refused

HEAD OF HOUSEHOLD Name:_______________________________________ Relationship to HOH: Self Date of Birth:______________ Social Security #:______________________________ Gender: M Ethnicity:___________ Pregnant? Y

N

DK

F

Race:_____________

If Yes, Due Date:______________

Housing Status: (check one)  Literally Homeless  Imminently losing their housing

 Unstably housed and at-risk of losing housing  Stably Housed

Education Information Currently in School? Y

N

Received Vocational Training? Y

N

Highest Level of Education Completed:_____________________________ Degree:_______________________ Veteran Information Are you a veteran? Y N

DK

R

Have you been in active duty? Y N DK R If yes, duration of active duty (in months)? ______ Have you ever served in a war zone? Y N DK      

Europe North Africa Vietnam Laos and Cambodia South China Sea China, Burma, India

R If so, which one? (check as many as applicable)     

Korea South Pacific Persian Gulf Afghanistan Other:___________________________

Branch of military?__________________ Discharge status? ___Honorable ___General ___Medical ___Bad Conduct ___Dishonorable ___Other Assessment Page 3

STABLE FAMILIES Assessment/Enrollment

35% AMI

2 Person $18,950

3 Person $21,300

4 Person $23,650

5 Person $25,550

6 Person $27,450

7 Person $29,350

8 Person $31,250

HEAD OF HOUSEHOLD (CONTINUED) Employment Information Are you employed? Y

N

If not employed are you looking? Y N

Cash Benefits/Income (documentation needed for most current 30 days past) Total Monthly Income for HoH $_______________ Sources of income (put amount next to source)

Veterans Benefits/Disability: $______________________ Alimony/Spouse Support: $________________________ Child Support: $_________________________________ Job (Earned Income): $____________________________ General Assistance: $_____________________________ Other:____________________________$____________ Pension from former job: $_________________________ Private Disability Insurance: $______________________

SSI Retirement Income: $_________________________ SSDI: $________________________________________ SSI: $__________________________________________ TANF/ADC: $___________________________________ Unemployment Income: $__________________________ Veterans Pension: $_______________________________ Workers Compensation: $__________________________ No Financial Resources: (check)__________

Non–Cash Benefits (documentation needed for most current 30 days) Food Stamps: $______________________ Medicaid: $_________________________ Medicare: $_________________________ SCHIP: $__________________________ WIC: $____________________________ VA Medical Services: $__________________ TANF Childcare Services: $_______________ TANF Transportation: $__________________ Other TANF: $_______________________ Section 8/Housing Assistance/Public Housing: $_____________________

Other:___________________________$_____________ Temporary Rental Assistance: $____________________ Total Monthly Non-Cash/Benefits for HoH: ______________

Assessment Page 4

STABLE FAMILIES Assessment/Enrollment ADULT #2 Name:____________________________________________________ Relationship to HOH _______________

Date of Birth:______________ Social Security #:______________________________ Gender: M F Race:_____________ Ethnicity:___________ Pregnant? Y

N

DK

R

If Yes, Due Date:______________

Disability Determination: Are you disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

Currently receiving services or treatment for this condition? (circle) Yes No Veteran Information Are you a veteran? Y N

DK

No Don’t Know Refused

R

Have you been in active duty? Y N DK R If yes, duration of active duty (in months)? ______ Have you ever served in a war zone? Y N DK

R If so, which one? (check as many as applicable)

Branch of military?__________________ Discharge status? ___Honorable ___General ___Medical ___Bad Conduct ___Dishonorable ___Other Education Information Currently in School?

Y

N

Received Vocational Training? Y

N

Highest Level of Education Completed: _____________________________ Degree: ______________________ Employment Information Are you Employed? Y N If not employed, are you looking?

Y

N

Total Monthly Income for Individual: ________________ Total Monthly Non-Cash/Benefits for Individual: ______________

Assessment Page 5

STABLE FAMILIES Assessment/Enrollment ADULT #3 Name:____________________________________________________ Relationship to HOH _______________

Date of Birth:______________ Social Security #:______________________________ Gender: M F Race:_____________ Ethnicity:___________ Pregnant? Y

N

DK

R

If Yes, Due Date:______________

Disability Determination: Are you disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

Currently receiving services or treatment for this condition? (circle) Yes No Veteran Information Are you a veteran? Y N

DK

No Don’t Know Refused

R

Have you been in active duty? Y N DK R If yes, duration of active duty (in months)? ______ Have you ever served in a war zone? Y N DK

R If so, which one? (check as many as applicable)

Branch of military?__________________ Discharge status? ___Honorable ___General ___Medical ___Bad Conduct ___Dishonorable ___Other Education Information Currently in School?

Y

N

Received Vocational Training? Y

N

Highest Level of Education Completed: _____________________________ Degree: ______________________ Employment Information Are you Employed? Y N If not employed, are you looking?

Y

N

Total Monthly Income for Individual: ________________ Total Monthly Non-Cash/Benefits for Individual: ______________

Assessment Page 6

STABLE FAMILIES Assessment/Enrollment CHILD #1 LIVING IN THE HOME Name: ____________________________________________ Relationship to HOH: _____________________ Date of Birth: _______________ Social Security #: __________________________________ Gender: M

F

Race: _______________

Ethnicity: ____________________

Education Information Is child school-aged? Yes

No

Currently In School? Y

If Yes, School Name: __________________________________________Circle one: Public

N

Private

If no, last date of enrollment: _________________________

Disability Determination: Is this child disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

No

Currently receiving services or treatment for this condition? (circle) Yes No

Don’t Know

Refused

Total Monthly Non Cash/Benefits for Individual: _______________________________________ CHILD #2 LIVING IN THE HOME Name: ____________________________________________ Relationship to HOH: _____________________ Date of Birth: _______________ Social Security #: __________________________________ Gender: M

F

Race: _______________

Ethnicity: ____________________

Education Information Is child school-aged? Yes

No

Currently In School? Y

If Yes, School Name: __________________________________________Circle one: Public

N

Private

If no, last date of enrollment: _________________________

Disability Determination: Is this child disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

Currently receiving services or treatment for this condition? (circle) Yes No

No Don’t Know

Refused

Total Monthly Non Cash/Benefits for Individual: _______________________________________ Assessment Page 7

STABLE FAMILIES Assessment/Enrollment CHILD #3 LIVING IN THE HOME Name: ____________________________________________ Relationship to HOH: _____________________ Date of Birth: _______________ Social Security #: __________________________________ Gender: M

F

Race: _______________

Ethnicity: ____________________

Education Information Is child school-aged? Yes

No

Currently In School? Y

If Yes, School Name: __________________________________________Circle one: Public

N

Private

If no, last date of enrollment: _________________________

Disability Determination: Is this child disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

No

Currently receiving services or treatment for this condition? (circle) Yes No

Don’t Know

Refused

Total Monthly Non Cash/Benefits for Individual: _______________________________________ CHILD #4 LIVING IN THE HOME Name: ____________________________________________ Relationship to HOH: _____________________ Date of Birth: _______________ Social Security #: __________________________________ Gender: M

F

Race: _______________

Ethnicity: ____________________

Education Information Is child school-aged? Yes

No

Currently In School? Y

If Yes, School Name: __________________________________________Circle one: Public

N

Private

If no, last date of enrollment: _________________________

Disability Determination: Is this child disabled? Y N DK R If you answered yes to disability, what type of disability do you have? Check all that applies. __Alcohol Abuse __Developmental Disability __Drug Abuse __HIV/AIDS __Mental Health Disability __Physical Disability __Both Alcohol & Drug Abuse __Chronic Health Condition Is the above condition going to be long term? (circle)

Yes

Currently receiving services or treatment for this condition? (circle) Yes No

No Don’t Know

Refused

Total Monthly Non Cash/Benefits for Individual: _______________________________________ Assessment Page 8

STABLE FAMILIES Assessment/Enrollment What is the type of residence prior to program entry (night before being assessed for the program)? _____ Emergency shelter, including a youth shelter, hotel, motel, or campground paid for with emergency shelter vouchers _____ Transitional housing for homeless persons including homeless youth _____ Permanent housing for formerly homeless persons such as SHP, S+C, or SRO Mod Rehab _____ Psychiatric hospital or other psychiatric facility _____ Substance abuse treatment facility or detox center _____ Hospital (non-psychiatric) _____ Jail, Prison, or Juvenile Detention Facility _____ Don’t Know _____ Refused _____ Rental by client, no housing subsidy (room, apartment, or house that they rent) _____ Owned by client, no housing subsidy (apartment or house they own) _____ Living with family (staying or living in a family members room, apartment, or house) _____ Hotel or motel without emergency shelter voucher _____ Foster care or group home _____ Place not meant for habitation (i.e. a vehicle, abandoned building, bus/train/subway station, airport, or anywhere outside) _____ Other, specify___________________________________________________________________________________ _____ Safe haven _____ Rental by client, with VASH housing subsidy _____ Rental by client with other (non-VASH) housing subsidy. Check type below: Project based subsidy? __________ Non-project based subsidy? (section 8 voucher) __________ _____ Owned by client, with housing subsidy How long have you been at your current residence (night before being assessed for the program)? _____ One week or less _____ More than one week, less than one month _____ One to three months

_____ More than three months, but less than one year _____ One year or longer _____ Don’t Know

_____ Within Franklin County (inside city-Columbus) _____ Within Franklin County (outside city-Columbus)

_____ Within Ohio but outside of Franklin County _____ Outside Ohio

Where was your previous residence located (night before being assessed for the program)? FOR ALL ADULTS IF APPLICABLE List address for previous residence (night before being assessed for the program) FOR ALL ADULTS IF APPLICABLE County:___________________________ ____________________

Street Address: ______________________________________ Zip Code:

Zip code of last permanent address (lived in longer than 90 days: ____________________________ How did your household come to be in this housing crisis P= Primary S= Secondary _____ Divorce/Separation _____ Loss of Job _____ Loss of Income _____ Medical emergency _____ Family violence (including physical and emotional abuse) _____ Alcohol and/or Drug issues _____ Mental disability _____ Rental eviction notice

_____ Relationship problems _____ Pregnancy _____ Household expansion required relocation _____ Physical health problems _____ Substandard housing _____ Eviction _____ Legal issues (utility arrears, etc)

Assessment Page 9

STABLE FAMILIES Assessment/Enrollment Please answer the following questions to determine if the client should be enrolled in the program: Is the client will to do case management? Yes No Is family willing to stay in contact for 12 months after termination to ensure that they are still stable? Yes No Does the client meet the income guidelines (35% OF THE AMI)? Family Size

1 Person 35% AMI

Yes

$16,600

2 People $18,950

3 People $21,300

4 People $23,650

5 People

6 People

$25,550

$27,450

7 People $29,350

8 People $31,250

No

Does the client have enough income to support their household after the receive our help (housing costs do not exceed 50% of monthly income)? Or are they going to have enough income soon? Yes No Is the landlord willing to work with the family? Yes No Is the amount owed reasonable for us to help with ($1200 or less)? Yes No If you answered YES to all of the above then the client can be enrolled. Please complete all enrollment and assessment paperwork now. If you answered NO, please say the following: It appears that your family is currently not a good fit for our program. If your circumstances change (getting employment, for example) please feel free to call us again to be re-screened for the program. In the meantime, you can check into the following community resources for other help: FEMA PRC Firstlink: 221-2255 YWCA Family Center: 253-3910 Local Churches

Is the client enrolled in the program after enrollment phase?

Yes

No

If no, why not: ______________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Assessment Page 10