Pathway of Hope Intake Form WUM 11-2018

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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

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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

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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