ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx

Residential Treatment Referral Worksheet Use this form for Veteran entry into the HCHV Contract Residential Treatment Program or HCHV Low Demand Safe Haven.

Assigned CM Staff Name (first and last name) ..……… Veteran’s name (last name, first initial)………………… Social Security number………………...……………….. ____ ____ ____ - ____ ____ - ____ ____ ____ ____ Date of birth (mm/dd/yy)………………………………… ____ ____ / ____ ____ / ____ ____

1. Date of screening decision for residential entry (mm/dd/yy): ____ ____ / ____ ____ / ____ ____

2. Date of program entry (mm/dd/yy): ____ ____ / ____ ____ / ____ ____

3. Continuum of Care (CoC) Location prior to entry:

4. Residential program:

What was the Veteran’s housing arrangement prior to program entry (location where the Veteran was sleeping prior to program entry)?

☐Housing owned by Veteran, no ongoing housing subsidy ☐Housing owned by Veteran, with ongoing housing subsidy ☐Housing rented by Veteran, no ongoing housing subsidy ☐Housing rented by Veteran with HUD-VASH voucher ☐Housing rented by Veteran with non-HUD-VASH housing subsidy ☐Permanent housing for formerly homeless persons (such as CoC project or S+C) ☐Staying or living with family, permanent tenure ☐Staying or living with family, temporary tenure ☐Staying or living with friends, permanent tenure ☐Staying or living with friends, temporary tenure ☐GPD transitional housing ☐Non-VA transitional housing for homeless persons ☐VA MH RRTP (Domiciliary)

☐CWT/TR

☐Non-VA residential treatment program ☐Non-VA substance abuse treatment facility or detox center ☐Hospital or other residential non-psychiatric medical facility ☐Long-term care facility or nursing home ☐Psychiatric hospital or other psychiatric facility ☐Prison or jail ☐VA contracted residential treatment program (HCHV Contract Residential Services) ☐Safe Haven ☐Hotel or motel paid for without emergency shelter voucher ☐Emergency shelter, including hotel or motel paid for with emergency shelter voucher ☐Place not meant for habitation (e.g. a vehicle, an abandoned building, bus/train/subway station or anywhere outside

4. How long did the Veteran stay in the location where he/she was residing prior to program entry (location where the Veteran was sleeping prior to program entry)?

☐One day or less ☐Two days to one week ☐More than one week, but less than one month ☐One to three months ☐More than three months but less than one year ☐One year or longer ☐Don’t know

5. Is the Veteran living with others at that location? (Yes/No)____No______ If Yes:

0. __Spouse/Significant other

0. __Children under 18 (number?)

0. __Related Adults (number?)

0. __Related Adults (number?)

6. How many months in total has the Veteran been homeless in the past three years? (If a Veteran was homeless for any part of a given month, round up and count that period as one month of homelessness.)___

7. What is the total number of times the Veteran has been homeless on the street, in Emergency Shelter (ES), or D Safe Haven (SH), in the past three years?

8. Is this Veteran a homeless individual with a disabling condition based on one of more of the following: A physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury that: (1) Is expected to be long-continuing or of indefinite duration; (2) Substantially impedes the individual’s ability to live independently; and (3) Could be improved by the provision of more suitable housing conditions.

(Yes/No)____No______

9. What is the zip code of the location where the Veteran was residing prior to program entry (if unknown, use current location)? _________________

10. In which Continuum of Care (CoC) was the Veteran residing prior to program entry (if unknown, use current location)?