FAMILY CASE RECORD ADMISSION/ASSESSMENT FORM

Facility’s Name:

CASE HEAD NAME ,  LAST                                            FIRST

	SOCIAL SECURITY
	
OTHER ADULT NAME, LAST                                         FIRST	PA/HRA # OR CIN #

MEDICAID #	PERMANENT RESIDENCE #	DURATION OF THA

DATE ADMITTED:

	DATE IN SYSTEM:	CASEWORKER:	

CASE COMPOSITION: Family members referred to shelter.

NAME LAST,                        FIRST	SOCIAL SECURITY	DOB	AGE	SEX	COMMENTS	
(HEAD OF HOUSEHOLD)

						

						

						

						

CASE COMPOSITION:            Family members not residing with family who may be included in rehousing.

NAME LAST,                        FIRST	SOCIAL SECURITY	DOB	AGE	SEX	COMMENTS	

						

						

EMERGENCY CONTACTS FOR FAMILY:
NAME: _________________________________                       NAME: _________________________________
ADDRESS:___________________________________                      ADDRESS: ______________________________
               ___________________________________                                     ______________________________
TELEPHONE: (     ) ____________________________                     TELEPHONE:  (     )  ______________________
RELATIONSHIP: ______________________________                      RELATIONSHIP:  ________________________
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1.	How long was the family homeless?   Years ____    Months _____ 

2.	Last temporary address.  ________________________________  City___________     State_________________

3.	Family's last permanent address. __________________________ City ___________    State ________________

4.	Reason for family's homelessness.________________________________________________________________

5.	Does the family have furniture? _____  Where?   ______________________  Date in storage _______________.

______________________________________________________________________________________________.

HEALTH INFORMATION:

1.	List all client medical needs below: 
CLIENT NAME	DOCTOR OR CLINIC	TELEPHONE #	SCREEN 
I OR II	MEDICAL NEED	

					

					

					

					

CHILD WELFARE SERVICES: 		
1.	Does the client have an active child protective/preventive case?                                                Yes      No  If yes, complete the following:
CHILD’S NAME	FOSTER CARE AGENCY	AGENCY WORKER	TEL. #	DATE ACTIVE	

					

					

2.	ACS Worker: _______________________Telephone: ______________  ACS Office: ______________________ .

3.	Did the case manager notify  ACS  5x8  at (718) 481-5817 of the family’s admission to the facility?   

4.	Date called:  _________ ACS worker spoke to:  ___________________  Status: _______________

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FAMILY HISTORY:
Has any member of the family been convicted of a crime?                                                            Yes      No  
 
 Who? _______________________    Explain: _________________________________________________________
 
_______________________________________________________________________________________________.

5.	Has any member of the family ever been on probation or parole?                                              Yes      No   
 Who? _______________________   Explain  __________________________________________________________

Probation/Parole Officer's Name: ____________________________ Tel. # __________________________________

DOMESTIC VIOLENCE SCREENING:
1.	Is the client or any member of the family a battered person?                                             	     Yes      No    
  If yes, complete the following.   Batterer’s Name: ____________________________  Relationship: ______________.

2.	Description of batterer: (Picture if possible) ________________________________________________________.

3.	Do you feel safe in your current location?                                                                               Yes      No 

4.	How frequent is your contact with the batterer?     ___________________________________________________

5.	When did you last have contact with the batterer?    Date ____________   Where? _________________________.

6.	Do you have an Order of Protection?                                                                                      Yes      No 
If “yes”, when does it expire?        Month  ___________     Day _________    Year _________ 

7.	What are the specified conditions of the Order of Protection (e.g., Batterer is not allowed within a certain distance of the survivor or batterer is not allowed to physically or verbally abuse the survivor.)  ______________________

_______________________________________________________________________________________________.

8.	If you do not have an Order of Protection, would you like assistance in obtaining one? 	     Yes      No 

9.	When was the last incident of violence?  Please describe.  _____________________________________________

______________________________________________________________________________________________.
 
10. Is anyone in the family receiving services for domestic of family violence? 			     Yes      No 

Name  of Individual Enrolled
In A DV  Program 	Type of Services	Program Name	Contact Person/Phone	

				

11.	 Do you have children in common with the batterer?                                                         	     Yes      No 
If “Yes”, who has custody of the children?                 (Check One)

    Client has sole custody         Batterer has sole custody              Client and batterer have joint custody 

    Other, please explain:  ________________________________________________________________________.

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DOMESTIC VIOLENCE SCREENING     (CONTINUED)

12.	Does the batterer have visitation with the children?                                                                 Yes      No 
If “Yes”’ what are the visitation arrangements or plans?  _________________________________________________

_______________________________________________________________________________________________.

13.	Does the batterer know where the children are enrolled in school?                           	                 Yes      No 

14.	If employed, does the batterer know your work location?                                                         Yes      No 

15.	Preliminary Safety Plan, if needed: ____________________________________________________________________________________________

_______________________________________________________________________________________________

PUBLIC ASSISTANCE INCOME:      (Check all that apply)
	Open   	Closed  	  Pending     		Ineligible     		Sanctioned    
 							AMOUNT 			AMOUNT
ENTITLEMENT						RECEIVING			ENTITLED TO

SEMI-MONTHLY GRANT					$_______.___			$________.___

RESTURANT ALLOWANCE				  _______.___			  ________.___

CARFARE ALLOWANCE					  _______.___			  ________.___
	
SHELTER GRANT					  _______.___			  ________.___

FOOD GRANT						  _______.___			  ________.___

SSI/SSD						  _______.___			  ________.___

OTHER BENEFITS: _____________________		  _______.___			  ________.___

IM CENTER/ADDRESS:  ___________________________________________________________________________

IM WORKER:  _____________________________________  TELEPHONE:  __________________________________

CHECK DATES:   1)  ____________________________________ 2)  _______________________________________

Client’s contribution to the cost of THA  $ _______  per month.  Payments to ___________________.

OTHER SERVICES INVOLVED:         (Note all other agencies providing service to the family).
  AGENCY NAME	      SERVICES	AGENCY WORKER	TELEPHONE  #	

				

Is anybody in the family a veteran? _______________.  If yes, who   ______________________________________.

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CLIENT EMPLOYMENT SCREENING:         (Complete separate employment screen for each adult client)

CLIENT NAME:  __________________________________________

U.S. CITIZENSHIP                                                                                                                      Yes      No 

IF NO,                             AUTHORIZATION TO WORK (EXP. DATE)  _____________________________

PRIMARY LANGUAGE:  __________________________________

ENGLISH PROFICIENCY:                           (Check all that apply)
   UNDERSTAND                    SPEAK                                 READ                                  WRITE

EDUCATION:
LAST GRADE COMPLETED:  ___________   YEAR:  __________.   GED COMPLETED:  ______  YEAR: ____________. 

1.	CLIENT ATTENDED COLLEGE,  FROM  __________  TO  ___________.   Degree, if any ____________________.

Comments:  ____________________________________________________________________________________.

 HAS THE CLIENT HAD ANY VOCATIONAL TRAINING IN ANY OF THE FOLLOWING AREAS:

   SECURITY	                     	   CLERICAL			    HEALTH/MENTAL HEALTH 
   CONSTRUCTION		    EDUCATION	      	                  FOOD SERVICE/PREPARATION
   RETAIL/SALES			    CHILDCARE                                     SERVICE INDUSTRY    
   TECHNOLOGY           		    SOCIAL SERVICES                           GOVERNMENT/CIVIL SERVICES
    MANUFACTURING   		    TRANSPORTATION                           OTHER:  ___________________

EMPLOYMENT INFORMATION:
2.	IS THE CLIENT CURRENTLY EMPLOYED? _______.  IF YES, COMPLETE THE FOLLOWING.

         FULL TIME                              PART TIME            UNDOCUMENTED EMPLOYMENT                       

NAME OF EMPLOYER:  _______________________ ADDRESS: __________________________________________

3.	HOW LONG IN THIS POSITION?  ____________________.  JOB TITLE:  _______________________________

4.	LIST DUTIES PERFORMED: ____________________________________________________________________.

WAGE:   $ _______________  PER:  _____________________  TOTAL YEARS EMPLOYED: ___________________.

5.	COMMENTS:   ______________________________________________________________________________.

AREA OF WORK-RELATED EXPERIENCE INCLUDING PAID AND VOLUNTEERED:     (Check all that apply)

   SECURITY				    CLERICAL		             HEALTH/MENTAL HEALTH 
   CONSTRUCTION			    EDUCATION		             FOOD SERVICE/PREPARATION
   RETAIL/SALES	    	            		    CHILDCARE                                SERVICE INDUSTRY     
   TECHNOLOGY                			   SOCIAL SERVICES                       GOVERNMENT/CIVIL SERVICES
    MANUFACTURING         			    TRANSPORTATION                     OTHER:  ___________________

											Page 5 of 8

CLIENT’S MOST SIGNIFICANT PAST EMPLOYMENT.   	IF APPLICABLE, COMPLETE THE FOLLOWING.

         FULL TIME                         		     PART TIME    		        UNDOCUMENTED EMPLOYMENT  
              
NAME OF EMPLOYER:  _______________________ ADDRESS: __________________________________________

6.	HOW LONG IN THIS POSITION: _____.  JOB TITLE:  ______________________________________________

7.	LIST DUTIES PERFORMED:  ___________________________________________________________________.

8.	WAGE:   $ _______________  PER:  _____________________  TOTAL YEARS EMPLOYED: ________________.

REASON FOR LEAVING LAST JOB.   ____________________________________________________________.

9.	EMPLOYMENT AREAS OF INTEREST:            (Check all that apply)

   SECURITY			        CLERICAL			  HEALTH/MENTAL HEALTH 
   CONSTRUCTION	 	         EDUCATION		   FOOD SERVICE/PREP
   RETAIL/SALES	   		         CHILDCARE                               SERVICE INDUSTRY     
   TECHNOLOGY               		         SOCIAL SERVICES                     GOVERNMENT/CIVIL SERVICES
    MANUFACTURING     		         TRANSPORTATION                     OTHER  ___________________

10.	CURRENT BARRIERS TO EMPLOYMENT:  DOES THE CLIENT BELIEVE THAT ANY OF THE FOLLOWING ARE SO SEVERE OR DEBILITATING AS TO SIGNIFICANTLY IMPEDE HIS/HER ABILITY TO PARTICIPATE IN EMPLOYMENT-RELATED ACTIVITIES?  (Check below)

   PHYSICAL HEALTH/DISABILITY			   MENTAL ILLNESS 		   SUBSTANCE ABUSE 
   CHILDCARE ISSUES			                 DOMESTIC VIOLENCE		   ENGLISH DEFICIENCY
   OTHER:  _____________________________

COMMENTS:  ___________________________________________________________________________________.

ALCOHOL/SUBSTANCE ABUSE SCREENING:            (Complete separate alcohol/substance abuse screening for each adult client)

CLIENT NAME:  ____________________________________________________

1.	In the last 12 months, did the client engage in drinking or drug use?   		             Yes       No  

2.	In the last 12 months, was the client hospitalized because of alcohol     			  Yes      No   or drug use?  Example: 1) Having been in an accident while drunk or high;  2) Having 
      a severe psychiatric problem like a suicide attempt after or during alcohol or drug use;
      or 3) Having an alcohol or drug overdose.)  ________________________________________________________.

3.	In the last 12 months, has the client ever lost a job or failed      				 Yes       No   
      to complete school or a training program due to alcohol or drug use?

4.	In the last 12 months, has the client ever tried unsuccessfully   			            Yes       No    
      to stop or greatly reduce the amount of drinking or drug use?

5.	In the last 12 months, has the client ever been in alcohol/ substance abuse treatment?           Yes      No    
      
Name of Program:  ___________________Counselor: ___________________Telephone:  (    )  _________________

Caseworker Recommendations: _____________________________________________________________________ 

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CHILD CARE CURRENT NEEDS:
LIST ALL PRESCHOOL AGE CHILDREN AGES 0 MONTHS THROUGH 5 YEARS WHO MIGHT NEED CHILD CARE WHEN THE CLIENT IS ACTIVELY SEEKING PERMANENT HOUSING, JOB TRAINING, EDUCATION OR EMPLOYMENT SERVICES.
 
NAME	AGE	TYPE OF CARE NEEDED	DAYS AND TIME NEEDED	

				

IF CHILD CARE IS CURRENTLY IN USE, COMPLETE THE FOLLOWING:
NAME	AGE	PERSON/AGENCY/TELEPHONE # 	DAYS AND TIME ATTENDED	

				

SPECIAL NEEDS: _______________________________________________________________________________

_____________________________________________________________________________________________.

SCHOOL-AGE CHILDREN’S EDUCATIONAL NEEDS:
NAME	GRADE	SCHOOL AND ADDRESS	SPECIAL NEED	

				

				

CHILREN’S RECREATION NEEDS:
          NAME	  AGE	        AGENCY/ON-SITE	  DAYS AND TIME NEEDED	

				

			

DESCRIBE ANY SPECIAL NEEDS:  ______________________________________________________.

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THE CLIENT MUST PROVIDE THE FOLLOWING DOCUMENTS:
ITEMS NEEDED	COMMENTS	ITEMS NEEDED	COMMENTS	
BIRTH CERTIFICATE		SS. CARD		
PA CARD		IMMUNIZATION 		
MEDICALS		FOOD STAMP		
PASSPORT		SCHOOL RECORDS		
BUDGET SHEET		CHILD WELFARE DOC.		
MEDICAID CARD		ORDER OF PROTECTION		
PAY STUBS		TRAINING RECORDS		
V.A. BENEFITS DD 214:		OTHER:		

COMMENTS:  ____________________________________________________________________

_______________________________________________________________________________.

CLIENT ASSESSED NEEDS: 
ALL FAMILY ASSESSED NEEDS MUST BE TRANSFERRED TO THE SERVICE PLAN/INDEPENDENT LIVING PLAN.  NEEDS MUST BE PRIORITIZED ACCORDING TO ACHIEVABLE GOALS WHICH WILL LEAD TO EMPLOYMENT (SELF-SUFFICIENCY) AND HOUSING OTHER THAN TEMPORARY HOUSING.
  TYPES OF SERVICE NEEDS	               DETAIL OF CLIENT NEEDS	
HOUSING		
CHILD/RECREATION		
COUNSELING		
EDUCATION		
JOB TRAINING		
EMPLOYMENT		
BENEFITS		
CHILD WELFARE		
MEDICAL		
PARENTING SKILLS		
UNDOCUMENTED INDIVIDUALS		
INDEPENDENT LIVING SKILLS		
LEGAL SERVICES		
SUBSTANCE/ALCOHOL ABUSE 		
COMMUNITY TIES		
DOMESTIC VIOLENCE		
MENTAL HEALTH		
OTHER		

COMMENTS:  ______________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________.

HEAD OF HOUSEHOLD: ________________________________	   DATE: ________________________

CASEWORKER’S SIGNATURE: __________________________      DATE:________________________

SUPERVISOR’S SIGNATURE:   ___________________________    DATE:_________________________

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