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Pathway of Hope Intake Form WUM 11-2018
1
Client Record
Date: HOH Name:
First Name Middle Name Last Name and Suffix SIMS ID#
U.S. Military Veteran?
☐ Yes ☐ No ☐ Client refused
☐ Client doesn’t know ☐Data not collected Are you receiving Veteran Services?
☐ Yes ☐ No
Phone: Email:
Street Address & Apt#:
Zip Code:
City, County, State:
Client Demographics:
Date of Birth: Gender: ☐ Male ☐ Female ☐ Client refused ☐ Client doesn’t know
☐ Transgender to Male ☐ Transgender to Female
☐ Gender non-conforming (i.e. not exclusively male or female)
Date of birth type: ☐ Full DOB Reported ☐ Approximate or Partial DOB Reported ☐ Client doesn’t know ☐ Client refused
Primary Race: ☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American
☐ Native Hawaiian or Other Pacific Islander ☐ White SOU ☐ R Client doesn’t know ☐ Client refused
Ethnicity: ☐ Non-Hispanic/Non-Latino ☐ Hispanic/Latino ☐ Client doesn’t know ☐ Client refused
Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Separated ☐ Widowed ☐ Minor
Other Information: Do you have a disabling condition? ☐ Yes ☐ No
☐Client doesn’t know ☐ Client refused
Covered by health insurance?
☐ Yes ☐ No
Household Type: ☐ Couple With No Children ☐ Foster Parent(s) ☐ Grandparent(s) and Child ☐ Single Parent
☐ Non-custodial Caregiver(s) ☐ Two Parent Family ☐ Single Adult ☐ Other
Relationship to HoH:
1. Self (head of household) 2. Head of household’s child 3. Head of household’s spouse or partner
4. Head of household’s other relation member 5. Other: non-relation member 6. Data not collected
List All Persons in Household* (Choose options from above lists)
Name Relationship to
HoH DOB Gender
Race Choose
Ethn Vet
Status Disabling Condition
Health Insure.
Marital Status
Household Income Noncash Benefits
Earned Income (HUD) SNAP (Food Stamps) (HUD)
SSI (HUD)
Special Supplemental Nutrition Program for WIC (HUD)
SSDI (HUD)
Monthly Household Income: Total: __________ Total Non-cash benefits: Total ____________
*Add additional Household Members on the back.
Include income for all members of the household.
Pathway of Hope Intake Form WUM 11-2018
2
Homeless Information: Residence Prior to Project Entry (Select from one of the three situation areas below)
-HOMELESS SITUATION-
☐ Place not meant for habitation
☐ Emergency shelter, including hotel or motel paid for with emergency shelter voucher
☐ Safe Haven
☐ Interim Housing If any of the four options above were selected, answer the following three bulleted items
Approximate date homelessness started: ___________
Regardless of where they stayed last night - Number of times the client has been on the streets, in ES, or SH in the past three years including today
Total number of months homeless on the street, in ES or SH in the past three years
☐One month (this is the first month (HUD) ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ 7 ☐ 8 ☐ 9 ☐ 10 ☐ 11 ☐ 12
☐More than 12 months ☐ Client doesn’t know ☐ Client Refused ☐ Data not collected
-INSTITUTIONAL SITUATION-
☐Foster care home or foster care group home
☐Hospital or other residential non-psychiatric medical facility
☐Jail, prison or juvenile detention facility
☐Long-term care facility or nursing home
☐Psychiatric hospital or other psychiatric facility
☐Substance abuse treatment facility or detox center If any of the six options above were selected, answer the following two bulleted items
Did you stay less than 90 days?
☐ Yes ☐ No Answer must coincide with the upcoming “Length of Stay in Previous Place” question
On the night before did you stay on the streets, ES or SH?
☐ Yes ☐ No
-TRANSITIONAL AND PERMAENT HOUSING SITUATION-
☐Hotel or motel paid for without emergency shelter voucher
☐Owned by client, no ongoing housing subsidy
☐Owned by client, with ongoing housing subsidy
☐Permanent housing (other than RRH) for formerly homeless persons
☐Rental by client, no ongoing housing subsidy
☐Rental by client, with VASH subsidy
☐Rental by client, with GPD TIP subsidy
☐Rental by client, with other ongoing housing subsidy (including RRH)
☐Residential project or halfway house with no homeless criteria
☐Staying or living in a family member’s room, apartment, or house
☐Staying or living in a friend’s room, apartment, or house
☐Transitional housing for homeless persons (including homeless youth)
☐Client doesn’t know
☐Client refused
☐Data not collected If any of the fifteen options above were selected, answer the following two bulleted items
Did you stay less than 7 nights? Answer must coincide with the upcoming “Length of Stay in Previous Place” question
On the night before did you stay on the streets, ES or SH? Regardless of housing situation described above, answer the following question: -LENGTH OF STAY IN PREVIOUS PLACE
☐ One night or less ☐ Two to six nights ☐ One week or more, but less than one month
☐ One week or more, but less than 90 days ☐ 90 days or more, but less than one year
☐ One year or longer ☐ Client doesn’t know ☐ Client refused ☐ Data not collected
Pathway of Hope Intake Form WUM 11-2018
3
Education
Degree Earned:
☐ None ☐ GED ☐ High School Diploma
☐ Associates ☐ Bachelors ☐ Masters ☐ Doctorate ☐ Other Graduate/Professional Degree
☐ Certification of Advanced Training/Skill Artisan ☐ Don’t Know ☐ Refused
Start Date: End Date: TYPE OF WORK (Standard Occupational Classification)
1. Management Occupations 2. Business and Financial Operations Occupations 3. Computer and Mathematical Occupations 4. Architecture and Engineering Occupations 5. Life, Physical, and Social Science Occupations 6. Community and Social Service Occupations 7. Legal Occupations 8. Educational Instruction and Library Occupations 9. Arts, Design, Entertainment, Sports, & Media
Occupations 10. Healthcare Practitioners and Technical Occupations 11. Healthcare Support Occupations
12. Protective Service Occupations 13. Food Preparation and Serving Related Occupations 14. Building and Grounds Cleaning and Maintenance
Occupations 15. Personal Care and Service Occupations 16. Sales and Related Occupations 17. Office and Administrative Support Occupations 18. Farming, Fishing, and Forestry Occupations 19. Construction and Extraction Occupations 20. Installation, Maintenance, and Repair Occupations 21. Production Occupations 22. Transportation and Material Moving Occupations 23. Military Specific Occupations
Work History (Current or most
recent): Employment Status:
☐ Full Time
☐ Part Time
☐ Seasonal Work
☐ Volunteer Work Only
Type of Work # (choose from above)
Employer’s Name:
Employer’s Address:
Start Date: End Date: Hourly Wage: If Ended,
Reason:
SOURCE OF CLIENT REFERRAL (Check one)☐Salvation Army Emergency Assistance Program
☐Salvation Army Residential Program
☐Salvation Army Corps Referral
☐Salvation Army Corrections Department
☐Salvation Army Seasonal Programs
☐Salvation Army - Other
☐Community Agency Referral
☐Community School or After-school Program Referral
☐Self-Referred
NOTES & ADDITIONAL INFORMATION
Intake and Selection: Working Together Agreement
What to expect from joining the Pathway of Hope The Salvation Army Pathway of Hope (POH) is a holistic approach designed to support you and your family as you take action to meet your aspirations and goals. Through your involvement, you will have opportunities to develop a network of support, enroll in healthy family programs and access resources based on your action plan. Hours & Appointments: To achieve maximum benefit from the program, you will be asked to meet with your caseworker or touch base by phone approximately once a week. Your caseworker will work with you to determine the best time to meet. It is expected that all appointments will be kept. Please notify your caseworker if you will need to cancel an appointment at least 24 hours in advance at: ____________________________________________________ Pathway of Hope: Once it is determined that you and your family are eligible, you’ll begin working with your caseworker to complete a comprehensive assessment and develop an action plan that includes steps to connect your family with needed services. Through your active participation and follow-up with these action steps, you and your family will gain the most benefit from your involvement with Pathway of Hope. Based upon your identified goals, you and your caseworker will decide how long you will work together. In the event that you repeatedly miss scheduled appointments and/or participate in activities that put yourself or others at risk, you may be asked to discontinue your involvement in the services offered through the Pathway of Hope. Fees: All services received through Pathway of Hope are provided at no charge to you. Confidentiality: Information you provide is considered confidential. This information is shared only with your written permission. Exceptions are related to state mandates that your caseworker will review with you. Grievance Policy: This agency provides its applicant or clients with a means of expressing and resolving a complaint or appeal. Clients have a right to raise questions about agency decisions concerning them or services provide. If you feel that a decision or service was unacceptable, you have the opportunity to present your point of view to the supervisor. If you experience difficulty with your caseworker or The Salvation Army, you have the right to use our client grievance procedure. A copy is available upon request. Consent for Use of Information: The Salvation Army conducts program evaluation to assess the effectiveness of Pathway of Hope. As part of this evaluation, information on your participation will be shared with the evaluation team. To insure the confidentiality (privacy) of your participation in the Pathway of Hope, your responses to questionnaires, surveys, assessment tools, and all identifying information will be voided except for a digitized ID code. The results of the evaluation will be used in compiled evaluation reports that may be used for quality improvement reports and publication, however, your identity will not be revealed. If you have any questions about our evaluation of the Pathway of Hope, please contact us at: xxx-xxx-xxxx Voluntary Participation Disclosure: Your signature below indicates that your participation in the Pathway of Hope program is completely voluntary.
S I G N A T U R E O F P A T H W A Y P A R T I C I P A N T
D A T E S I G N A T U R E O F P A T H W A Y W O R K E R
D A T E
Approved by The Salvation Army Central Territory SIMS Committee on 10.17.17
The Salvation Army Client Data Management System
Client Privacy Notice & Consent
NOTICE:
We collect personal information directly from you for reasons that are discussed in The Salvation Army Client Data
Management System Privacy Policy and Guidelines. We may be required to collect some personal information by law
or by organizations that give funds to us to operate this program. Other personal information that we collect is
important to run our programs, to improve services, and to better understand the needs of those we serve. We only
collect information that we consider to be appropriate. The collection and use of all personal information is guided by
strict standards of confidentiality. A copy of our privacy policy is available to all clients upon request.
YOUR RIGHTS:
You have the right to a copy of the information about you in a Client Data Management System as outlined in the
Client Data Management System Privacy Policy. You have the right to correct mistakes on information about you.
If you have a complaint about the performance of any Salvation Army staff member, officer, intern, volunteer, or feel
treated unfairly in any way, you can follow the grievance policy steps as outlined in the Client Data Management
System Privacy Policy. Grievances may be formally recording by making an appointment to speak with or submit a
written complaint to The Salvation Army’s Unit Director at the location you are being served.
If you do not want your name, social security number, or date of birth entered in a Client Data Management System,
tell the intake worker and circle the applicable section below. The Salvation Army will not refuse to help you for
denying this. However, this option may not be applicable to certain services including, but not limited to, specific
SSVF and utility assistance services. They will enter you into the system as an anonymous individual and keep your
identifiable information separate.
If applicable circle the statement in italics: I am refusing to allow my identifiable information to be entered a Client
Data Management System and understand that my intake information will be entered as an anonymous client. I
understand that my identifiable information will be stored separately in a secure database for anonymous clients.
SIGNED CONSENT
Each adult, emancipated minor or unaccompanied youth must sign for him or herself. A parent/guardian should sign
for children under the age of 18. My signature shows that I permit you to enter my personal information into a Client
Data Management System.
_________________________________ ____ /____/____
Print Name- Client Date of Birth
_________________________________ ____ /____/____ _________________________________ ____ /____/____
Signature of Client or Guardian Date Signed Signature of Witness Date Signed
If Applicable Dependent Children under 18:
_________________________________ ____ /____/____ _________________________________ ____ /____/____
Print Name Date of Birth Print Name Date of Birth
_________________________________ ____ /____/____ _________________________________ ____ /____/____
Print Name Date of Birth Print Name Date of Birth
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PE R F O R M A N C E M E A S U R E M E N T A N D C L I E N T T O O L S , P O L I C I E S , A N D P R O C E D U R E S
Selection: URICA Client Assessment Tool
Client Information
Client:
Caseworker:
Date:
Description of the Situation
This questionnaire is to help improve our services. Each statement describes how a person might feel when starting to get help. Please indicate the extent to which you tend to agree or disagree with each statement. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. For all the statements that refer to your “situation,” answer in terms of how you have described your situation at the top. There are FIVE possible responses to each of the items in the questionnaire: Strongly disagree, disagree, undecided, agree, and strongly agree. Mark an X in the box that best describes how much you agree or disagree with each statement.
There are FIVE possible responses: Strongly Disagree
Disagree Undecided Agree Strongly
Agree
1. It doesn’t make much sense for me to consider changing my situation.
2. I’ve been thinking that I might want to improve my situation.
3. At times my situation causes problems and I’m determined to change it.
4. It is frustrating, but I feel I might be having a recurrence of a bad situation that I thought I had fixed.
5. Trying to change my situation is pretty much a waste of time.
6. I guess I have faults, but there’s nothing that I really need to change about my situation.
7. I thought once I had improved my situation everything would be fine, but sometimes I still find myself struggling.
8. My situation is not good and I think I should work to improve it.
9. I am really working hard to improve my situation.
10. I hope that someone will have some good advice for me about how to improve my situation.
11. Anyone can talk about changing their situation; I’m actually going to do something about it.
12. After all I had done to try and improve my situation, every now and then I still find myself struggling.
Herth Hope Index Tool Listed below are a number of statements. Read each statement and place an [X] in the box that describes how much you agree with that statement right now.
Strongly Disagree
Disagree Agree Strongly
Agree
Item Score
1. I have a positive outlook toward life.
2. I have short and/or long range goals
3. I feel all alone.
4. I can see possibilities in the midst of difficulties.
5. I have a faith that gives me comfort.
6. I feel scared about my future.
7. I can recall happy/joyful times.
8. I have deep inner strength.
9. I am able to give and receive caring/love.
10. I have a sense of direction.
11. I believe that each day has potential.
12. I feel my life has value and worth.
Total Score
© 1989 Kaye Herth
1999 items 2 & 4 reworded
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Client Sufficiency Matrix Tool Domain
Client Score 1 2 3 4 5
Income No income. Inadequate income
and/or spontaneous or inappropriate spending.
Can meet basic needs with subsidy;
appropriate spending.
Can meet basic needs and manage
debt without assistance.
Income is sufficient, well managed; has
discretionary income and is able to save.
Employment No job. Temporary, part-time or
seasonal; inadequate pay, no benefits.
Employed full time; inadequate pay;
few or no benefits.
Employed full time with adequate pay
and benefits.
Maintains permanent employment with
adequate income and benefits.
Housing Homeless or
threatened with eviction.
In transitional, temporary or
substandard housing; and/or current
rent/mortgage payment is unaffordable (over
30% of income).
In stable housing that is safe but only
marginally adequate.
Household is in safe, adequate
subsidized housing.
Household is safe, adequate, unsubsidized
housing.
Food
No food or means to
prepare it. Relies to a significant
degree on other sources of free
or low-cost food.
Household is on food stamps.
Can meet basic food needs, but
requires occasional assistance.
Can meet basic food needs
without assistance.
Can choose to purchase any food household
desires.
Childcare
Needs childcare, but none is available/ accessible
and/or child is not eligible.
Childcare is unreliable or unaffordable,
inadequate supervision is a problem for childcare that is
available.
Affordable subsidized childcare is
available, but limited.
Reliable, affordable childcare is
available, no need for subsidies.
Able to select quality childcare of choice.
Children’s Education
One or more eligible children not enrolled in
school.
One or more eligible children enrolled in
school, but not attending classes.
Enrolled in school, but one or more
children only occasionally
attending classes.
Enrolled in school and attending
classes most of the time.
All eligible children enrolled and attending
on a regular basis.
Adult Education
Literacy problems and/or
no high school diploma/GED are serious barriers to employment.
Enrolled in literacy and/or GED program and/or has sufficient
command of English to where language is not a barrier to employment.
Has high school diploma/GED.
Needs additional education/training
to improve employment
situation and/or to resolve literacy
problems to where they are able to
function effectively in society.
Has completed education/training needed to become
employable. No literacy problems.
Legal
Current outstanding
tickets or warrants.
Current charges/trial pending,
noncompliance with probation/parole.
Fully compliant with
probation/parole terms.
Has successfully completed
probation/parole within past 12
months, no new charges filed.
No active criminal justice involvement in more that 12 months
and/or no felony criminal history.
Health Care No medical
coverage with immediate need.
No medical coverage and great difficulty
accessing medical care when needed. Some household members
may be in poor health.
Some members (e.g. Children) on
Medicaid/Medicare/Other Gov.
Insurance Program
All members can get medical care
when needed, but may strain budget.
All members are covered by affordable,
adequate health insurance.
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DOMAIN Client
Score 1 2 3 4 5
Life Skills
Unable to meet basic needs such as
hygiene, food, activities of daily
living.
Can meet a few but not all needs of
daily living without assistance.
Can meet most but not all daily living
needs without assistance.
Able to meet all basic needs of daily
living without assistance.
Able to provide beyond basic needs of daily living for self and
family.
Mental Health
Danger to self or others; recurring suicidal ideation;
experiencing severe difficulty in day-to-
day life due to psychological
problems.
Recurrent mental health symptoms that may affect
behavior, but not a danger to
self/others; persistent problems
with functioning due to mental
health symptoms.
Mild symptoms may be present but are
transient; only moderate difficulty
in functioning related to mental health problems.
Minimal symptoms that are expectable
responses to life stressors; only slight
impairment in functioning.
Symptoms are absent or rare; good or
superior functioning in wide range of
activities; no more than every day
problems or concerns.
Substance Abuse
Meets criteria for severe
abuse/dependence; resulting problems
so severe that institutional living or hospitalization may be necessary.
Meets criteria for dependence;
preoccupation with use and/or obtaining
drugs/alcohol; withdrawal or
withdrawal avoidance behaviors evident; use results
in avoidance or neglect of essential
life activities.
Use within last 6 months; evidence of
persistent or recurrent social,
occupational, emotional or
physical problems related to use (such
as disruptive behavior or housing
problems); problems have
persisted for at least one month.
Client has used during last 6
months, but no evidence of
persistent or recurrent social,
occupational, emotional, or
physical problems related to use; no
evidence of recurrent
dangerous use.
No drug use/alcohol abuse in last 6 months.
Family Relations
Lack of necessary support form family
or friends; abuse (DV, child) is
present or there is child neglect.
Family/friends may be supportive, but
lack ability or resources to help;
family members do not relate well with
one another; potential for abuse
or neglect.
Some support from family/friends;
family members acknowledge and
seek to change negative behaviors;
are learning to communicate and
support.
Strong support from family or friends.
Household members support
each other’s efforts.
Has health/expanding support network;
household is stable and communication is
consistently open.
Mobility
No access to transportation,
public or private; may have car that is
inoperable.
Transportation is available, but
unreliable, unpredictable,
unaffordable; may have care but no
insurance, license, etc.
Transportation is available and
reliable, but limited and/or
inconvenient; drivers are licensed
and minimally insured.
Transportation is generally accessible to meet basic travel
needs.
Transportation is readily available and
affordable; car is adequately insured.
Community Involvement
Not applicable due to crisis situation; in
“survival” mode.
Socially isolated and/or no social
skills and/or lacks motivation to
become involved.
Lacks knowledge of ways to become
involved.
Some community involvement
(advisory group, support group), but has barriers such as
transportation, childcare issues.
Actively involved in community.
Strengths Assessment Categories
& Self Sufficiency Matrix Domains to Consider
Current Situation What’s going on today?
Desires and Aspirations What do I want?
Resources What have I used in the past?
What’s available now?
Daily Living Situation Food
Housing
Life Skills
Mobility
Childcare
Family Finances Income
Employment
Housing
Childcare
Legal
Mobility
Education (Youth & Adult) Childcare
Children’s Education
Adult Education
Social Supports Family Relations
Community Involvement
Mobility
Family Health Health Care
Mental Health
Substance Abuse
Spirituality Family Relations
Community Involvement
Client Name: ____________________________ SIMS ID: ____________________
Corps/Church and Community Engagement Questionnaire
Client Initials/SIMS ID #:_____________________________ Date Completed: ____________________________
Involvement in other Salvation Army programs is strictly voluntary. As such, there is no penalty for non-participation, or
advantage for participating with other Salvation Army programs concerning your current Pathway of Hope case
management.
Please respond to the following regarding your activity in the last 3 months…
Has the family attended church or other religious services? (Circle one)
Yes
No
Doesn’t know
If yes, did the family attend...: (Circle one)
The Salvation Army
A Local Church
Other Religious Services
The Salvation Army and other locations
Have any children participated in character building/spiritual development programming? (Circle one)
Yes
No
Doesn’t know
If yes, where?: (Circle one)
The Salvation Army
A Local Church
Elsewhere in the Community
The Salvation Army and Other Locations
Have any adults participated in spiritual development programming?
Yes
No
Doesn’t know
If yes, where? (Circle one)
The Salvation Army
A Local Church
Elsewhere in the Community
The Salvation Army and Other Locations
If The Salvation Army, did they attend…(Circle one)
Bible Study
Women’s/Men’s Ministries
Both of the above
------------------------------------------------------------------------------------------------------------------------------------------
Upon Exit only, complete the following questions based on activities since Entry.
Did anyone in the family participate in volunteer service? (Circle one)
Yes, at The Salvation Army
Yes, elsewhere in the Community
Yes, both The Salvation Army and the Community
No
Did anyone in the family become a soldier(s) as a result of participating in POH? (Circle one)
Yes
No
Doesn’t know
Did anyone in the family become an adherent(s) as a result of participating in POH? (Circle one)
Yes
No
Doesn’t know