Fhpap all-Inclusive Assessment

Download 98.5 Kb.
Size98.5 Kb.
FHPAP All-Inclusive Assessment

  • Complete for head of household only. If there are additional household members 18 and older, complete separate Universal Assessments for each of them.

  • Please see the Appendix on the back of this page for definitions of terms used in this assessment. All terms with definitions are underlined.

Client Name: __________________________________ Service Point ID: ________________
Assessment Date (program entry date): _____ /_____/ ________

Month Day Year

Part I: Universal Assessment

1. At the time of program entry, what was the extent of the client’s homelessness (based on Minnesota’s definition)?

 Not homeless
 First time homeless AND less than one year without home

Multiple times homeless, but not meeting long-term homeless definition

 Long term: homeless at least 1 year OR at least 4 times in the past 3 years

2. Had the client left any of the places listed below in the 90 days before entering the program?
 No: continue to question 3  Yes: select the most recent place left:

 Adoptive Home (from foster care system)

 County Jail or Workhouse Youth

Drug or Alcohol Treatment Facility

Mental Health Treatment Facility or Hospital

 Combined MI/CD treatment facility

Foster Home

Group Home

Half-way House

 Juvenile Detention Center

 Orphanage

Residence for People with Physical Disabilities

 Don’t Know

 State or Federal Prison

 Refused

3. Living situation last night (HUD): Where did the client stay the night before entering this program?

Emergency shelter

 Transitional housing for homeless

Permanent housing for formerly homeless

 Psychiatric hospital or facility

 Substance abuse treatment center, including detox

 Hospital

 Jail, prison, or juvenile facility

 Don’t Know

 House/apartment rented by client

 House/apartment owned by client

Living with family

 Living with friends

 Hotel/motel without emergency shelter

 Foster care/group home

 Place not meant for habitation

 Other

 Refused

4. Length of stay: How long had the client been staying at that place?

 1 week or less

 Over 1 week, less than 1 month

 1 to 3 months

 Over 3 months, less than 1 year

 1 year or longer

5. How long has it been since the client lived at a permanent address? (90+ days; not shelter or time-limited housing)

FHPAP Prevention clients: select “current residence” and continue to question 7.

 Current Residence

 Less than 1 month

 1 to 3 months
 3 to 6 months

 6 to 12 months

 1 to 2 years
 3 to 5 years

 6 to 8 years

 9 years or more

6. Please record the client’s last permanent address:
_______________ ___________________ _________________________ _________

State County (MN only) City (MN only) Zip Code

6a. Zip code data quality:  Full 5-digit zip code recorded  Don’t know  Refused
Please continue to the next page to complete the FHPAP All-Inclusive Assessment.

7. Please record the client’s income in the grid below after reading these instructions:

  • Enter each adult client’s income on his/her own record.

  • Do not enter income from children’s jobs. Do enter payments received on a child’s behalf (such as disability payments) on the head of household’s record.

Income at Entry

Income Source (enter # from list below)

Last 30 day income (leave blank for noncash income)

Start Date

End date (record only if income source ends or changes)



program entry date




program entry date




program entry date




program entry date


Income Changes: update at exit

Income Source (enter # from list below)

Last 30 day income (leave blank for noncash income)

Start Date

End date (record only if income source ends or changes)

















No Sources of Income:
(1) No financial resources (no cash income source and no non-cash benefits) (H)

Cash Income Sources:

(2) Earned Income (H)

(3) Unemployment insurance (H)

(4) Supplemental Security Income (SSI) (H)

(5) Social Security Disability Income (SSDI) (H)

(6) A Veteran’s disability payment (H)

(7) Private disability insurance (H)*

(8)Worker’s compensation (H)*

(9) TANF (MFIP) (H)

(10) General Assistance (H)

(11) Retirement income from social security (H)

(12) Veteran’s pension (H)

(13) Pension from a former job (H)*

(14) Child support (H)*

(15) Alimony or other spousal support (H)*

(16)Contributions from other people*

(17) Interest (bank), dividends, or annuities*

(18) MSA/Minnesota Supplemental Aid*

(19)Student grants/scholarship*

(20) Tribal Funds*

(21) Other income source*: _______________

Non cash benefits:

(22) Food Stamps (H)

(23) MEDICAID – Medical Assistance (H)

(24) Medicare (H)

(25) SCHIP – MN care for children (H)

(26) Special supplemental nutrition program-WIC (H)

(27) Veteran’s Administration (VA) medical svcs. (H)

(28) TANF Child Care Services (H)

(29) TANF transportation services (H)

(30) Other TANF-Funded Services (H)

(31) Section 8, public housing or rental assistance (H)

(32) MN Care (for adults)*

(33) GAMC – General Assistance Medical Care*

(34) Other non cash benefits: ________________________________________

(H): Income source is approved for HUD funding. (*): Will be reported as “other” on the HUD Annual Progress Report.

8. Please record the client’s disabilities below (if the client has no disabilities, continue to question 9):

Mark if Mark if

Present Long-term (Y/N) Disability Type Present Long-term (Y/N) Disability Type

 ___ Alcohol abuse (H)

 ___ Developmental disability/mental

retardation (H)

 ___ Drug abuse (H)

 ___ HIV/AIDS (H)

 ___ Mental illness (H)

 ___ Physical/medical (H)

 ___ Traumatic brain injury*

 ___ Physical/mobility limits (H)

 ___ Hearing impaired*

 ___ Vision impaired*

 ___ Other *

(*) indicates disability type that will be reported as “other” on the current HUD Annual Progress Report.

9. Does the client have a long-term disability? (answer only if client is 18 or older):
 Yes  No  Don’t know  Refused to answer

10. Has the client ever served on active duty in the United States Armed Forces? (answer only if client is 18 or older):
 Yes  No  Don’t know  Refused to answer

Part II: FHPAP Assessment
11. City client lives in while receiving FHPAP assistance: ___________________________

12. County client lives in while receiving FHPAP assistance: _________________________

13. Is the FHPAP program in Hennepin or Ramsey County?  Yes  No
If yes: What is the client’s current FHPAP goal? (select one):
 Goal 1a: Prevention - stabilize in home

 Goal 1b: Prevention - re-house immediately

 Goal 2: Reduce length of homelessness

 Goal 3: Eliminate repeat episodes (if client entered homeless)

Part III: Barriers to Housing Stability Assessment


  • Complete one assessment per household and record all information on this form.

  • Some information may be collected after program entry as you get to know the household and learn about their barriers over time. You may enter this information into HMIS at a later date, but remember that it should describe the household’s situation at entry (remember to backdate).

  • Avoid using the “Not Assessed” category. Funders expect complete data collection for all clients served. Only mark “Not Assessed” if you are unable to get certain information from clients.

14. Do any household members have tenant screening barriers to getting housing?
 Yes  No (skip to question 17)  Not assessed (skip to question 17)

15. How many evictions or unlawful detainers have household members experienced?
 Zero  1  2-3  4-9 10+  Not assessed

16. Please complete the grid below:

 Have any household members experienced these tenant screening barriers?



Not Assessed (use rarely)

Poor reference from current/prior landlords




Lack of rental history




Unpaid rent or utility bills




Lack of or poor credit history




One or more misdemeanors




Critical felony (sex crime, arson, drugs)




Other felony




17. Do any household members have income barriers to getting or keeping housing?
 Yes  No Not assessed

18. Does the household need temporary assistance to get or keep housing?
 Yes  No  Not assessed

19. Is the household currently housed?  Yes  No
If yes: What percent of income does the household spend on housing?
 35% or less  36% to 50%  51% to 65%  66% to 80%  More than 80%  Not assessed
If no: How much money is the household able to spend per month on housing?
 Zero  $1-$100  $101-$151  $151-$200  $201-$250  $251-$300  $301-$350
 $351-400  $401-$450  $450-$500  $501-$550  $551-$600  $601-$700  $701-$800
 $801+  Not assessed

20. Please complete the grid below:

 Have any household members experienced these income barriers?



Not Assessed

(use rarely)

Lacks steady, full time employment




Lacks high school diploma or GED




Job barrier: limited English proficiency




Job barrier: lack of reliable transportation




Job barrier: lack of reliable/affordable child care





Drug or Alcohol Treatment Facility: Includes inpatient treatment and detox.
Extent of Homelessness by Minnesota’s Definition

The State of Minnesota defines as homeless “any individual, unaccompanied youth or family that is without a permanent place to live that is fit for human habitation.” Doubling-up is considered homeless if that arrangement has persisted less than 1 year.

The State of Minnesota defines an individual, unaccompanied youth or family as “Long-Term Homeless” if they are without a home for a year or more OR have had at least four (4) episodes of homelessness in the past three (3) years. Any period of institutionalization or incarceration (including transitional housing, prison/jail, treatment, hospitals, foster care, or refugee camps) shall be excluded when determining the length of time the household has been homeless.
Foster Home: In question 2, this term applies to youth only.
Group Home: Includes mall facility for people with disabilities (cognitive or physical); may also be used for corrections clients. Includes adult foster care. Placement done through social services or corrections departments.
Half-way House: Includes placement for corrections clients after jail or prison OR for clients after chemical dependency treatment.
Mental Health Treatment Facility or Hospital: Includes regional treatment centers (state hospitals), Intensive Residential Treatment Services (IRTS), crisis residences, and psychiatric inpatient units at local hospitals.
Permanent address: A permanent address is an apartment, house, or room where the client last lived for 90 days or more. Shelters and time-limited housing are not permanent addresses.
Residence for People with Physical Disabilities: Includes nursing homes, long-term care facilities, and rehab hospitals.
U.S. Military Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States for 180 OR MORE days. This does not include inactive military reserves or the National Guard unless the person was called up to active duty

Wilder Research of Updated 1/2009

Share with your friends:

The database is protected by copyright ©dentisty.org 2019
send message

    Main page