vulnerability index - service prioritization decision...

Vulnerability Index - Service Prioritization Decision Assistance Tool (VI-SPDAT) Prescreen Triage Tool for Famlies Formatted for use in Seattle/King County Oct 2015. Based on VI-SPDAT 2.0 developed by OrgCode Consulting Inc. and Community Solutions, 2015

FAMILIES TOOLAdministration

Interviewer’s Name

Interviewer's Phone

Staff Volunteer

Survey Date Month/Day/Year Survey Time Survey Location

Opening ScriptMy name is _________________, and I am a _________________ (role) with the _________________ (program). I have a 10 minute survey I would like to complete with you. Most questions require only a YES or NO answer. Some questions require a one-word answer. I'll be honest, some questions are personal in nature. The purpose of these questions is to help us understand your housing and service needs so we can best match you with appropriate resources. Keep in mind you can skip or refuse any question. The information is protected and stored in the Seattle/King County Housing Connections database, a secure database that helps us connect people with housing, based on the needs and experiences you identify and the housing programs you are eligible for in King County.

All the information you tell me is confidential and you should share as much as you feel comfortable. The more information you feel comfortable sharing, the smoother the referral process will be because we will know your options and won’t waste your time referring to you programs you aren’t eligible for. I do not make assumptions and I’m required to ask each question to everyone. Please bear with me if an answer feels obvious or repetitive. If you have any questions during the assessment or want clarification, just let me know. Do you have any questions before we start?

Basic Information

Parent 1: First Name Nickname Last Name

In what language do you feel best able to express yourself?

Social Security Number Consent to participateDate of Birth Age

Yes No

IF 9L¢I9w I9!5 hC Ih¦9Ih[5 IS 60 YEARS OF AGE OR OLDER, THEN SCORE 1. AGE SCORE:

Interviewer’s Email

AgencyTeam

Parent 2: First Name Nickname Last Name

In what language do you feel best able to express yourself?

Social Security Number Consent to participateDate of Birth Age

Yes No

No second parent currently part of household

A. History of Housing and Homelessness5. Where do you and your family sleep most frequently? (check one)

Outdoors (location) Other (specify): Refused

IF THE PERSON ANSWERS ANYTHING OTHER THAN “SHELTER”, “TRANSITIONAL HOUSING”, OR “SAFE HAVEN”, THEN SCORE 1. SLEEP LOCATION SCORE A1:

6. How long has it been since you and your family lived inpermanent stable housing?

7. In the last three years, how many times have you and our familybeen homeless?

Refused

Refused

IF THE FAMILY HAS EXPERIENCED 1 OR MORE CONSECUTIVE YEARS OF HOMELESSNESS, AND/OR 4+ EPISODES OF HOMELESSNESS THEN SCORE 1. CH SCORE A2:

Shelters (if known, which: _____________________________) Transitional Housing (if known, which: ________________) Safe Haven(if known, which: ____________________________)

Children

1. How many children under the age of 18 are currently with you?

2. How many children under the age of 18 are not currently with your family, butbut you have reason to believe they will be joining you when you get housed?

3. IF HOUSEHOLD INCLUDES A FEMALE: Is any member of thefamily currently pregnant?

4. Please provide a list of children’s names and ages:

First Name Last Name AgeDate of Birth

IF THERE IS A SINGLE PARENT WITH 2+ CHILDREN, AND/OR A CHILD AGED 11 OR YOUNGER, AND/OR A CURRENT PREGNANCY, THEN SCORE 1 FOR FAMILY SIZE.

IF THERE ARE TWO PARENTS WITH 3+ CHILDREN, AND/OR A CHILD AGED 6 OR YOUNGER, AND/OR A CURRENT PREGNANCY, THEN SCORE 1 FOR FAMILY SIZE.

FAMILY SIZE

SCORE:

Yes No Refused

Refused

Refused

B. Risks8. In the past six months, how many times has anyone in your family...

a) Received health care at an emergency department/room? Refused

b) Taken an ambulance to the hospital? Refused

c) Been hospitalized as an inpatient? Refused

d) Used a crisis service, including sexual assault crisis, mental health crisis,family/intimate violence, distress centers and suicide prevention hotlines?

Refused

e) Talked to police because they witnessed a crime, were the victim of a crime, or the al- leged perpetrator of a crime or because the police told them they must move along?

Refused

f) Stayed one or more nights in a holding cell, jail or prison, whether that was ashort-term stay like the drunk tank, a longer stay for a more serious offence, oranything in between?

IF THE TOTAL NUMBER OF INTERACTIONS EQUALS 4 OR MORE, THEN SCORE 1 FOR EMERGENCY SERVICE USE. RISK SCORE B1:

9. Have you or anyone in your family been attacked or beaten up sincethey’ve become homeless?

10. Have you or anyone in your family threatened to or tried to harm themself oranyone else in the last year?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF HARM.

Y N Refused

11. Do you or anyone in your family have any legal stuff going on right now thatmay result in them being locked up, having to pay fines, or that make it moredifficult to rent a place to live?

IF “YES,” THEN SCORE 1 FOR LEGAL ISSUES. RISK SCORE B3:

12. Does anybody force or trick you or anyone in your family to do things thatthey do not want to do?

Y N Refused

13. Do you or anyone in your family ever do things that may be considered to berisky like exchange sex for money, run drugs for someone, have unprotectedsex with someone they don’t know, share a needle, or anything like that?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF EXPLOITATION. RISK SCORE B4:

C. Socialization & Daily Functioning14. Is there any person, past landlord, business, bookie, dealer, or government

group like the IRS that thinks you or anyone in your family owes them money?

Do you or anyone in your family get any money from the government, apension, an inheritance, working under the table, a regular job, or anythinglike that?

IF “YES” TO QUESTION 10 OR “NO” TO QUESTION 11, THEN SCORE 1 FOR MONEY MANAGEMENT.

SOCIAL SCORE C1:

Does everyone in your family have planned activities, other than just surviving, that make them feel happy and fufilled?

IF “NO,” THEN SCORE 1 FOR MEANINGFUL DAILY ACTIVITY. SOCIAL SCORE C2:

15.

16.

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Refused

TOTAL RISK SCORE B1+B2+B3+B4:

RISK SCORE B2:

Is everyone in your family currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other things like that?

IF “NO,” THEN SCORE 1 FOR SELF-CARE.

Is your family's current homelessness in any way caused by a relationship that broke down, an unhealthy or abusive relationship, or because other family or friends caused your family to become evicted?

IF “YES,” THEN SCORE 1 FOR SOCIAL RELATIONSHIPS.

SOCIAL SCORE C3:

C. Socialization & Daily Functioning (continued)

17.

18.

SOCIAL SCORE C4:

D. Wellness19. Has your family ever had to leave an apartment, shelter program, or other place

you were staying because of the physical health of you or anyone in your family?

20. Do you or anyone in your family have any chronic health issues with his/herliver, kidneys, stomach, lungs or heart?

21. If there was space available in a program that specifically assists people thatlive with HIV or AIDS, would that be of interest to you or anyone in your family?

Does anyone in your family have any physical disabilities that would limit the typeof housing you could access, or would make it hard to live independently becauseyou’d need help?

When someone in your family is sick or not feeling well, does yourfamily avoid getting medical help?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR PHYSICAL HEALTH. WELLNESS SCORE D1:

22.

23.

Has drinking or drug use by anyone in your family led your family family to be kicked out of an apartment or program where you were staying in the past?

25. Will drinking or drug use make it difficult for your family to stay housed orafford your housing?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR SUBSTANCE USE. WELLNESS SCORE D2:

Has your family ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program or other place you were staying, because of:a) A mental health issue or concern?

b) A past head injury?c) A learning disability, developmental disability, or other impairment?

Does anyone in your family have any mental health or brain issues that would make it hard for your family to live independently because help would be needed?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR MENTAL HEALTH. WELLNESS SCORE D3:

24.

26.

27.

IF THE FAMILY SCORED 1 EACH FOR PHYSICAL HEALTH, SUBSTANCE USE AND MENTAL HEALTH: Does any single member of your household have a medical condition and mental health concerns and experience with problematic substance abuse

WELLNESS SCORE D4:

Y N Refused

Y N Refused

Y N Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

N

N

N

N

N

N

N

N

N

N

SOCIAL SCORE C1+C2+C3+C4:

28.

IF “YES”, THEN SCORE 1 FOR TRI-MORBIDITY.

29. Are there any medications that a doctor said you or anyone in your familyshould be taking that, for whatever reason, they are not taking?

30. Are there any medications like painkillers that you or anyone in your familydon’t take the way the doctor prescribed or where they sell the themedication?

WELLNESS SCORE D5:

31 YES OR NO: Has your family's current period of homelessness beencaused by an experience of emotional, physical, psychological, sexual, or other type of abuse, or by any other trauma you or anyone in your have experienced?

IF “YES”, SCORE 1 FOR ABUSE AND TRAUMA. WELLNESS SCORE D6:

IF "YES” TO ANY OF THE ABOVE, SCORE 1 FOR MEDICATIONS

Y N Refused

Y N Refused

Y Refused N

WELLNESS SCORE D1+D2+D3+D4+D5+D6:

E. Family Unit32. Are there any children that have been removed from the family by

a child protection service within the last 180 days?

33. Do you have any family legal issues that are being resolved in courtor need to be resolved in court that would impact your housing orwho may live within your housing?

IF “YES” TO ANY OF THE ABOVE, SCORE 1 FOR FAMILY LEGAL ISSUES. FAMILY UNIT SCORE E1:

34. In the last 180 days have any children lived with family or friendsbecause of your homelessness or housing situation?

35. Has any child in the family experienced abuse or trauma in the last180 days?

36. IF THERE ARE SCHOOL-AGED CHILDREN: Do your childrenattend school more often than not each week?

37. Have the members of your family changed in the last 180 days, due tothings like divorce, your kids coming back to live with you, someoneleaving for military service or incarceration, a relative moving in, oranything like that?

38. Do you anticipate any other adults or children coming to live withyou within the first 180 days of being housed?

IF “YES” TO ANY OF THE ABOVE, SCORE 1 FOR FAMILY STABILITY.

Y N

FAMILY UNIT SCORE E3:

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Refused

Y N Refused

Y N Refused

FAMILY UNIT SCORE E2:

Scoring Summary by Domain SUBTOTAL

RESULTS

Score: Recommendation:

0-3: no housing intervention

4-8: an assessment for Rapid Re-Housing

9+: an assessment for Permanent Supportive Housing/Housing First

PRE SURVEY: AGE ƻŦ ŜƛǘƘŜǊ ǇŀǊŜƴǘ 60+

A. HISTORY OF HOUSING & HOMELESSNESSA1. Sleep ScoreA2. Chronic Homelessness Score

.. RISKS

C. SOCIALIZATION & DAILY FUNCTIONS

D. WELLNESS

GRAND TOTAL:

Follow-Up Questions

On a regular day, where is it easiest to find you and what time of day is easiest to do so?

place:

time:

Is there a phone number and/or email where someone can safely get in touch with you or leave you a message?

phone: -

email:

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There are just a few more questions that I'd like to ask you. Some of these questions help determine basic eligibility for different housing programs - items such as your gender, veteran status for programs that serve specific populations. May I ask you these additional questions? [Assessor - go to supplemental questions ]

Closing ScriptThank you for completing this pre-screening. I will forward this information to the Seattle/King County Veteran Housing Placement Team, and your information will be included in the list of people who need housing and services. This list is prioritized, with a goal to house people with the most severe needs and longest periods of homelessness first. The team meets weekly to review the assessments and housing options. We know from experience that it can take awhile to find housing, and you will likely hear from someone in the next three weeks to let you know which agency will be working with you and where you are on the list. If you don't hear from them in three weeks, contact me so I can follow up. Let me check again that your contact information is correct so that when we try to find you we have the right information. [Assessor - check phone/email.]

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39. Do you have two or more planned activities each week as a family such as outingsto the park, going to the library, visiting other family, watching a family move, or anything like that?

40. After school, or on weekends or days when there isn’t school, is the total time childrenspend each day where there is no interaction with you or another responsible adult...

a) 3 or more hours per day for children aged 13 or older?

b) 2 or more hours per day for children aged 12 or younger?

41. I F THERE ARE CHILDREN BOTH 12 AND UNDER & 13 AND OVER:Do your older kids spend 2 or more hours on a typical day helping their younger sibling(s) with things like getting ready for school, helping with homework, making them dinner, bathing them, or anything like that?

IF “NO” TO QUESTION 39, OR “YES” TO ANY OF QUESTIONS 40 OR 41, SCORE 1 FOR PARENTAL ENGAGEMENT. FAMILY UNIT SCORE E4:

Y N Refused

Y N Refused

Y N Refused

Y N Refused

FAMILY UNIT TOTAL SCORE E1+E2+E3+E4:

E. FAMILY UNIT /4

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FAMILY SIZE

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King County Supplemental Questions to the VI-SPDAT for Single Adults (v. 6-1-15)

Finally I’d like to ask you some questions to help us better understand homelessness, match you with appropriate

housing and services, and improve housing and support services.

LAST KNOWN PERMANENT ADDRESS for:

Street Address

City State Zip

Address Data Quality:

HAVE YOU EVER SERVED IN THE US MILITARY

IF YES, Did you serve at least one day of Active Military Duty?

IF YES, Are you registered for VA Healthcare?

IF YES, What was your characterization of serivce (discharge status)

WHAT IS YOUR GENDER

ETHNICITY [All clients]

RACE More than one race is permitted. [All clients] (Client doesn’t know and Client refused should only be selected if no other response is selected. )

ARE YOU REQUIRED TO REGISTER AS A SEX OFFENDER [This question helps match people to programs that have different criteria. Answering yes does not automatically make client ineligible for housing.]

Full address reported Incomplete or estimated address reported

Refused Client doesn’t know Data not collected

Yes No Refused Client doesn’t know



Dishonorable Honorable General (Under Honorable) Other Than Honorable (OTH) Bad Conduct

Uncharacterized Client doesn’t know Client refused

Male Female

Transgender Male to Female Transgender Female to Male

Other Client refused Client doesn’t know

Non-Hispanic / Non-Latino Hispanic / Latino

Client doesn’t know Client refused

Asian White Black or African American Native Hawaiian or Other Pacific Islander

Client doesn’t know Client refused

American Indian or Alaskan Native


King County Supplemental Questions to the VI-SPDAT for Single Adults

INCOME AND SOURCES [Head of household and adult] Yes No Amount per Month

/ mo None (No Financial Resources) VA Service-Connected Disability Compensation Alimony or other spousal support Child support Earned income (i.e., employment income)

General Assistance (GA) Pension or retirement income from a former job Private disability insurance Retirement Income from Social Security Social Security Disability Income (SSDI) Supplemental Security Income (SSI) Temporary Assistance for Needy Families (TANF) Unemployment Insurance VA Non-Service-Connected Disability Compensation Worker’s Compensation Other source (specify) : Client doesn’t know Client refused

Total

HEALTH INSURANCE Select all current source(s) of health insurance coverageMedicaid (a.k.a. WA Apple Health) Medicare

Employer-Provided Health Insurance COBRA Private Health Insurance No Health Insurance

Doesn't Know Refused Not Collected

Veteran's Administration (VA) Medical ServicesQualified Health Plan (a.k.a. Obamacare)

/ mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo

/ mo

VI-SPDAT Triage Notes

Note if unsheltered (Outdoors or Other). Where Staying:Outdoors Other

Shelter Plan

Review of Essential Elements and Quality AssuranceParent 1 First Name

Total Score

Discharge status Honorable General (Under Honorable) Other Than Honorable (OTH) Bad Conduct Dishonorable Uncharacterized Client doesn’t know Client refused

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/1

/1

/4

/4

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Parent Age Score

Family Size/Child Age Score

A1: Sleeping Place Score

A2: Chronic Homeless Score

B: Risk Score

C: Social/Functioning Score

D: Wellness Score

E. Family Unit Score

Screening Agency

Interviewer

Quality Assurance [Assessor - make sure you have FULLY completed / attached the following]Signed KC Release of Information Signed VA Release of Information (WITH agencies Initialed!)

Safe Harbors Consent

KC Supplemental Questions to the VI-SPDAT

Refused ES

TH

Save Haven

Carry Forward of Key Screening Answers

Served in the Military - YES One Day Active Duty - YES Registered with VA - YES

Registered Sex Offender - YES

Interview Date

times/3 yrsor

Outdoors Other

NOTES FROM VOLT (to be filled out only after VOLT placement team conferencing

FINAL HOUSING NOTES:

Income Total /mo. And note if any income sources are DISABILITY related (check box)

VA Svc-Connected Disability

Private Disability

SSIVA Non-Svc-Connected Disability SSDI

GA / GA-U

NOTES TO CONVEY TO VOLT / PLACEMENT TEAM

Discussed at VOLT (date ) Referred to (Houser/Agency):

Other Follow Up / Notes: Referred to (Navigator):

Please staple together in this order:1) essential elements review2) VI-SDPAT3) Supplemental Q's4) ROI's (VA, VHOG, SH Consent)

Parent 1 Age Parent 2 Age

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Child Age(s)

Parent 2 First Name

P 2Last

NO 2nd Parent

OR

P 1Last

Tri-Morbidity Score D4:

INTRODUCTION TO RELEASE OF CONFIDENTIAL INFORMATION FORHOUSING PLACEMENT AND SUPPORT SERVICES IN KING COUNTY

________________________________________________________________________________________www.allhomekc.org

Next are the HMIS Client Information Sheet and Client

Consent for Data Collection and Release of Information (ROI)

and the VA ROI. These forms explain the purpose of data

collection, the type of information collected, the risks and

benefits of sharing information, and the safeguards we take

to protect your information. By reading and signing the Client

Consent, you're giving us permission to talk with other

agencies and coordinate your entry into housing and services

for you. We can then all work together to help you find

housing. The purpose and intent of this form is to connect you

with housing resources, and if we talk to other agencies, we

will only share information that is directly related to helping

to find you housing and services. We won't share anything

else.

The following pages contain the HMIS Client Information Sheet, Client Consent for Data Collection & Release of Information (ROI), and Veterans Administration ROI. Below is suggested language to introduce these documents so individuals understand the context for using these forms and safeguards in place for protecting an individual's information.

401 Fifth Avenue Seattle, WA 98104

548 Market St #60866 San Francisco, CA 94104

(206) 444-4001 Homeless Management Information System

Client Information Sheet

What is the HMIS System? HMIS stands for Homeless Management Information System, and is a requirement for all programs and agencies providing services to low-income and homeless households with the support of federal funds. The HMIS is a data system that stores information about homelessness services

What is the purpose of the HMIS System? The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services.

Why is this type of information being collected? Client data will be used by local, state, and federal officials to better address the needs of the homeless. Gathering certain basic information (race, date of birth, family size, etc.) about you and the members of your household is a requirement of the federal and local funding which supports this program.

How can the HMIS System benefit me, the client? By gathering this information on you only once –you can be served by other agencies without reporting all the details (date of birth, social security number, last address, etc.) again and again. If there is a reason that providing your name or the name of other members of your household would place you (or your household member) at risk, then you can request that your information NOT be shared with other agencies. You have the right to revoke the sharing of your information at any time simply by completing a “Client Revocation of Consent to Release Information” form. This form is available at any HMIS-participating agency.

Also, by using the information you provide for the HMIS, you and your case worker can work together to identify the housing and services you need and work to obtain them.

Who has access to your information? Only the staff who work directly with you, or who have administrative responsibilities in this organization will be authorized to look at, enter, or use information that is kept in your file. Report developers and HMIS staff may also see your data. There are strict legal guidelines for who has access to your information, and it is protected by electronic encryption.

What are your rights as a client? You may be required to answer some questions as a prerequisite for a program, but there will be other questions you can choose not to answer. You have a right to view your record and to correct inaccurate information. You also have a right to a copy of your record. We will also NEVER give any information (health, medical needs, mental health, domestic violence, etc.) about you to anyone outside this organization, UNLESS YOU GIVE WRITTEN CONSENT, or as required by law through a subpoena or a court order. Personally identifying information, such as names and birthdays, will be removed seven years after my last recorded HMIS activity. You will receive services whether or not you allow your personally identifying information to be entered into HMIS.

This form may not be amended except on approval of the HMIS Steering Committee Please send all requests for changes to: [email protected]

KING COUNTY HMIS CLIENT INFORMATION SHEET (Version1.3 31Mar2016) Page 1 of 1

King County Homeless Management Information System (HMIS)Client Consent for Data Collection and Release of Information

What is the HMIS? The HMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the HMIS for King County. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).

What is the purpose of this form? With this form, you can give permission to have information about you collected and shared with Partner Agencies that help King County provide housing and services. A current list of Partner Agencies is at http://kingcounty.hmis.cc/participatingagencies/

BY SIGNING THIS FORM, I AUTHORIZE King County and Bitfocus to share HMIS information with Partner Agencies. The HMIS information shared will be used to help me get housing and services. It will also be used to help evaluate the quality of housing and service programs. I understand that the Partner Agencies may change over time.

The information to be collected and shared includes: Name, birthday, gender, race, ethnicity, social security number, phone number, address Basic medical, mental health, substance use, and daily living information Housing Information Use of crisis services, hospitals and jail Employment, income, insurance and benefits information Services provided by Partner Agencies Results from assessments My photograph or other likeness (if included)

BY SIGNING THIS FORM, I UNDERSTAND THAT:

King County, Bitfocus and Partner Agencies will keep my HMIS information private using strictprivacy policies. I have the right to review their privacy policies.

There is a small risk of a security breach, and someone might obtain my information and use itinappropriately.

If I have questions about my privacy rights, my HMIS information, or am concerned that myinformation has been misused, I can contact my HMIS systems administrator at (206) 4444001 x2.

I can receive a copy of this Consent and the Client Information Sheet

I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.

This Consent will expire 7 years from my last HMIS recorded activity.

KING COUNTY HMIS CLIENT CONSENT TO DATA COLLECTION AND ROI (Version1.3 30Mar2016)

I may revoke this Consent earlier at any time in writing to:

Bitfocus, Inc. ATTN: King County HMIS 548 Market St #60866 San Francisco, CA 941045401

The revocation will take effect upon receipt, except to the extent others have already acted under thisConsent.

My HMIS information may be viewed by auditors or funders who review work of the PartnerAgencies, including HUD, The Department of Veteran Affairs, The Department of Health and HumanServices, and The Washington State Department of Commerce. I understand that the list of auditorsand funders may change over time.

My HMIS information may be shared to coordinate referral and placement for housing and services.

My HMIS information may be further shared by the Partner Agencies to other agencies for carecoordination, counseling, food, utility assistance, and other services.

My HMIS information will be combined with other information from the Washington State Departmentof Social and Health Services (DSHS) to help evaluate the quality of social services.

My HMIS information may be used for research; however, my identity will remain private.

Important: Personal information is not entered in HMIS for people who are 1) receiving services from domestic violence agencies; 2) fleeing or in danger from domestic violence, dating violence, sexual assault or stalking situation; or 3) have revealed information about being HIV positive or having AIDS. If one of these situations applies to you, DO NOT agree to have your personal identifying information collected.

SIGNATURE:

______________________________________ Signature of Patient/Client or Representative:

______________________________________ PRINTED NAME

_________________ Date


King County Homeless Management Information System (HMIS)Client Consent for Data Collection and Release of Information

What is the HMIS? The HMIS is a data system that stores information about homelessness services. Bitfocus, Inc. manages the HMIS for King County. The purpose of the HMIS is to improve services that support people who are homeless to get housing, and to have better access to those services, while meeting requirements of funders such as the U.S. Department of Housing and Urban Development (HUD).

What is the purpose of this form? With this form, you can give permission to have information about you collected and shared with Partner Agencies that help King County provide housing and services. A current list of Partner Agencies is at http://kingcounty.hmis.cc/participatingagencies/

BY SIGNING THIS FORM, I AUTHORIZE King County and Bitfocus to share HMIS information with Partner Agencies. The HMIS information shared will be used to help me get housing and services. It will also be used to help evaluate the quality of housing and service programs. I understand that the Partner Agencies may change over time.

The information to be collected and shared includes: Name, birthday, gender, race, ethnicity, social security number, phone number, address Basic medical, mental health, substance use, and daily living information Housing Information Use of crisis services, hospitals and jail Employment, income, insurance and benefits information Services provided by Partner Agencies Results from assessments My photograph or other likeness (if included)

BY SIGNING THIS FORM, I UNDERSTAND THAT:

King County, Bitfocus and Partner Agencies will keep my HMIS information private using strictprivacy policies. I have the right to review their privacy policies.

There is a small risk of a security breach, and someone might obtain my information and use itinappropriately.

If I have questions about my privacy rights, my HMIS information, or am concerned that myinformation has been misused, I can contact my HMIS systems administrator at (206) 4444001 x2.

I can receive a copy of this Consent and the Client Information Sheet

I may refuse to sign this Consent. If I refuse, I will not lose any benefits or services.

This Consent will expire 7 years from my last HMIS recorded activity.


I may revoke this Consent earlier at any time in writing to:

Bitfocus, Inc. ATTN: King County HMIS 548 Market St #60866 San Francisco, CA 941045401

The revocation will take effect upon receipt, except to the extent others have already acted under thisConsent.

My HMIS information may be viewed by auditors or funders who review work of the PartnerAgencies, including HUD, The Department of Veteran Affairs, The Department of Health and HumanServices, and The Washington State Department of Commerce. I understand that the list of auditorsand funders may change over time.

My HMIS information may be shared to coordinate referral and placement for housing and services.

My HMIS information may be further shared by the Partner Agencies to other agencies for carecoordination, counseling, food, utility assistance, and other services.

My HMIS information will be combined with other information from the Washington State Departmentof Social and Health Services (DSHS) to help evaluate the quality of social services.

My HMIS information may be used for research; however, my identity will remain private.

Important: Personal information is not entered in HMIS for people who are 1) receiving services from domestic violence agencies; 2) fleeing or in danger from domestic violence, dating violence, sexual assault or stalking situation; or 3) have revealed information about being HIV positive or having AIDS. If one of these situations applies to you, DO NOT agree to have your personal identifying information collected.

SIGNATURE:

______________________________________ Signature of Patient/Client or Representative:

______________________________________ PRINTED NAME

_________________ Date


OMB Number: 290090260 Estimated burden: 2 Minutes Expiration Date: 10/31/3003

REQUEST FOR AND AUTHORIZATION TO RELEASE OF MEDICAL RECORDS OR HEALTH INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We expect that the time expended by all individuals completing this form will average 2 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to specifically outline the circumstances under which we may disclose data

The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a and 38 U.S.C 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will not be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED.

TO: Department of Veterans Affairs (Print or type name

and address of Health care facility)

VA Puget Sound Health Care System 1660 S. Columbian Way, Seattle, WA 98108

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED.

PATIENT WILL INITIAL ALL OF THE BELOW APPLICABLE TO THIS AUTHORIZATION TO RELEASE. ____Bellwether Housing ____Bread of Life Mission ____BitFocus Homeless Management Information System ____Capitol Hill Housing

____Catholic Community Services ____Catholic Housing Services ____Chief Seattle Club ____Community Psychiatric Clinic ___Compass Housing Alliance

___Congregations for the Homeless ____DESC _____El Centro de la Raza ____Evergreen Treatment Services/REACH ____Harborview Medical Center

____Housing Authorities: King, Seattle, Renton ____Hopelink ____Imagine Housing ____ITFH ____King County Department of Community & Human Services

____LIHI ____Multi Service Center ____NAVOS ____Operation Nightwatch ____Pioneer Human Services ____Plymouth Housing Group ____Salvation Army

____Seattle Indian Health Center ____Seattle-King County Public Health ____Seattle Human Services/Office of Housing ____SHARE/WHEEL

____Sound Mental Health ____Solid Ground ____St. Vincent de Paul ____Therapeutic Health Services ____Union Gospel Mission ____United Way King County

____Valley Cities Counseling & Consultation ____Vietnam Veterans Leadership Program ____Washington State Department of Veterans Affairs ____YWCA ____Other: ______________________________

____SELECT ALL LISTED AGENCIES

VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to the

organization, or individual named on this request. I understand the information to be released include information regarding the following

condition(s):

DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE HUMAN IMMUNODEFICIENCY VIRUS (HIV) SICKLE CELL ANEMIA

INFORMATION REQUESTED: (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each)

COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT NOTE(S) OTHER (Specify) VA medical, Answers from VI-SPDAT/VI-Family-SPDAT survey, demographic information, veteran status, income amount and source, legal information, use of case management, and VA healthcare eligibility.

PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

For intake purposes, housing placement and referral, case management, coordination.

NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information

given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on year of signature (date supplied by patient: or (3) under the following condition(s): Discharge from the VA Community Housing and Outreach Services programs. NOTE: The authorization signed on this release will not exceed one year from the date signed.

Date: Signature of Patient or Person Authorized to Sign for Patient

FOR VA USE ONLY

IMPRINT Patient Data Card (Name, Address, Social Security

Number) Type and Extent of Material Released

Date Released Released By:

VA FORM 10-5345 MAR 2003 THIS SUPERSEDES VA FORM 10-5345, DATED JUN.2001, WHICH WILL NOT BE USED

Department of Veterans Affairs

OMB Number: 290090260 Estimated burden: 2 Minutes Expiration Date: 10/31/3003

REQUEST FOR AND AUTHORIZATION TO RELEASE OF MEDICAL RECORDS OR HEALTH INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We expect that the time expended by all individuals completing this form will average 2 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to specifically outline the circumstances under which we may disclose data

The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a and 38 U.S.C 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will not be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED.

TO: Department of Veterans Affairs (Print or type name

and address of Health care facility)

VA Puget Sound Health Care System 1660 S. Columbian Way, Seattle, WA 98108

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED.

PATIENT WILL INITIAL ALL OF THE BELOW APPLICABLE TO THIS AUTHORIZATION TO RELEASE. ____Bellwether Housing ____Bread of Life Mission ____BitFocus Homeless Management Information System ____Capitol Hill Housing

____Catholic Community Services ____Catholic Housing Services ____Chief Seattle Club ____Community Psychiatric Clinic ___Compass Housing Alliance

___Congregations for the Homeless ____DESC _____El Centro de la Raza ____Evergreen Treatment Services/REACH ____Harborview Medical Center

____Housing Authorities: King, Seattle, Renton ____Hopelink ____Imagine Housing ____ITFH ____King County Department of Community & Human Services

____LIHI ____Multi Service Center ____NAVOS ____Operation Nightwatch ____Pioneer Human Services ____Plymouth Housing Group ____Salvation Army

____Seattle Indian Health Center ____Seattle-King County Public Health ____Seattle Human Services/Office of Housing ____SHARE/WHEEL

____Sound Mental Health ____Solid Ground ____St. Vincent de Paul ____Therapeutic Health Services ____Union Gospel Mission ____United Way King County

____Valley Cities Counseling & Consultation ____Vietnam Veterans Leadership Program ____Washington State Department of Veterans Affairs ____YWCA ____Other: ______________________________

____SELECT ALL LISTED AGENCIES

VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to the

organization, or individual named on this request. I understand the information to be released include information regarding the following

condition(s):

DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE HUMAN IMMUNODEFICIENCY VIRUS (HIV) SICKLE CELL ANEMIA

INFORMATION REQUESTED: (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each)

COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT NOTE(S) OTHER (Specify) VA medical, Answers from VI-SPDAT/VI-Family-SPDAT survey, demographic information, veteran status, income amount and source, legal information, use of case management, and VA healthcare eligibility.

PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

For intake purposes, housing placement and referral, case management, coordination.

NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information

given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on year of signature (date supplied by patient: or (3) under the following condition(s): Discharge from the VA Community Housing and Outreach Services programs. NOTE: The authorization signed on this release will not exceed one year from the date signed.

Date: Signature of Patient or Person Authorized to Sign for Patient

FOR VA USE ONLY

IMPRINT Patient Data Card (Name, Address, Social Security

Number)

Type and Extent of Material Released

Date Released

Released By:

VA FORM 10-5345

MAR 2003 THIS SUPERSEDES VA FORM 10-5345, DATED JUN.2001, WHICH WILL NOT BE USED

Department of Veterans Affairs

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