Download MHT Exit Form template

Mobile Housing Team (MHT) OUTREACH EXIT FORM
ServicePoint Client ID for Head of Household: _____________
This is the cover page for EXIT data that needs to be collected when a family exits from MHT Outreach.
In addition to this page, fill out the following pages to update information about each member of the household.
Make additional copies as necessary.
** If housing placement was made with MHT Rapid Re-Housing for this family, the EXIT portion of the MHT
Housing Placement Form also needs to be completed.
EXIT Date from MHT Outreach: ______/______/______
NOTE: In general, the exit date is determined by the type of housing placement:
 For placement with MHT Rapid Re-Housing (RRH), the exit date is the same date as exit from RRH.
 For placement with Housing Choice Voucher (HCV), the exit date is the day before entry into HCV.
Reason for Leaving:
 Completed Program
 Criminal Activity/Violence
 Death
 Disagreement with
Rules/Persons
 Non-payment of rent
 Reached maximum time allowed
 Left for housing opportunity before
completing program
 Needs could not be met
Destination:
 Emergency Shelter (inc. hotel/motel paid for with
shelter voucher)
 Permanent housing for formerly homeless persons
 Place not meant for habitation streets/cars/buses/parks/etc
 Rental by client, no ongoing housing subsidy
 Rental by client, with other ongoing housing subsidy
 Staying or living with family, permanent
In Permanent Housing?
Updated 3.1.16
 Non-compliance with program
 Unknown/Disappeared
 Other (specify):
________________________________
 Staying or living with family, temporary
 Staying or living with friends, permanent
 Staying or living with friends, temporary
 Transitional housing for homeless persons
 No exit interview completed
 Client doesn’t know
 Client refused
 Other: (describe)
_____________________
 Yes, client is exiting program with permanent housing
 No, client is exiting program without permanent housing
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Mobile Housing Team (MHT) OUTREACH EXIT FORM
HEAD OF HOUSEHOLD (HoH) EXIT Data (page 1 of 1)
Name: _________________________________________
Disability
Type at Exit:
None
Client Refused
Client Doesn’t Know
Mental Health Physical
Chronic Health
Drug Abuse
Alcohol Abuse
HIV/AIDS
Hearing Impaired
Vision Impaired
Developmental
Other: ____________________________________
Health
Insurance at
Exit:
None
Client Refused
Client Doesn’t Know
Medicaid (OHP)
Medicare
VA Medical Services
Private Pay
Other: __________________________
Continuous and
Ongoing Non-Cash
Benefits at Exit
(Select all that apply)
Employer Provided
None
Client Refused
Client Doesn’t Know
WIC
TANF Child Care Services
Supplemental Nutrition Assistance (SNAP)
TANF Transportation Services
Section 8, Public Housing, or other rental assistance
Other (Describe):__________________________________________________
Employment Status at Exit: Full-Time
Part-Time
Not Employed – Not Seeking
Job Training Irregular
Not Employed – Seeking
Retired
Continuous and Ongoing Income at Exit (Fill in all that apply. Do not count if one time, ended, or ending soon):
None
Client Refused
Client Doesn’t Know
Monthly Amount
Monthly Amount
_____________ Supplemental Security Income (SSI)
_____________ Retirement Income from Social Security
_____________ Social Security Disability Income (SSDI) _____________ Self Employment Wages
_____________ TANF
_____________ Unemployment Insurance
_____________ Earned Income (wages, salary, etc)
_____________ Veterans Disability Payment
_____________ Alimony or other Spousal Support
_____________ Veterans Pension
_____________ Child Support
_____________ Retirement Income from Social Security
_____________ Pension from a former job
_____________ Worker’s Compensation
_____________ Private Disability Insurance
_____________ Other: _________________________
Updated 3.1.16
Head of Household (page 1 of 1)
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Mobile Housing Team (MHT) OUTREACH EXIT FORM
For each additional adult in the household, please make copies of this section.
OTHER ADULT (18+ yrs of age) EXIT Data (page 1 of 1)
Name: _________________________________________
Disability
Type at Exit:
None
Client Refused
Client Doesn’t Know
Mental Health Physical
Chronic Health
Drug Abuse
Alcohol Abuse
HIV/AIDS
Hearing Impaired
Vision Impaired
Developmental
Other: ____________________________________
Health
Insurance at
Exit:
None
Client Refused
Client Doesn’t Know
Medicaid (OHP)
Medicare
VA Medical Services
Private Pay
Other: __________________________
Continuous and
Ongoing Non-Cash
Benefits at Exit
(Select all that apply)
Employer Provided
None
Client Refused
Client Doesn’t Know
WIC
TANF Child Care Services
Supplemental Nutrition Assistance (SNAP)
TANF Transportation Services
Section 8, Public Housing, or other rental assistance
Other (Describe):__________________________________________________
Employment Status at Exit: Full-Time
Part-Time
Not Employed – Not Seeking
Job Training Irregular
Not Employed – Seeking
Retired
Continuous and Ongoing Income at Exit (Fill in all that apply. Do not count if one time, ended, or ending soon):
None
Client Refused
Client Doesn’t Know
Monthly Amount
Monthly Amount
_____________ Supplemental Security Income (SSI)
_____________ Retirement Income from Social Security
_____________ Social Security Disability Income (SSDI) _____________ Self Employment Wages
_____________ TANF
_____________ Unemployment Insurance
_____________ Earned Income (wages, salary, etc)
_____________ Veterans Disability Payment
_____________ Alimony or other Spousal Support
_____________ Veterans Pension
_____________ Child Support
_____________ Retirement Income from Social Security
_____________ Pension from a former job
_____________ Worker’s Compensation
_____________ Private Disability Insurance
_____________ Other: _________________________
Updated 3.1.16
Adult (page 1 of 1)
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Mobile Housing Team (MHT) OUTREACH EXIT FORM
For each additional child in the household, please make copies of this section.
CHILD (under 18 years of age) EXIT Data (page 1 of 1)
Name: _________________________________________
Current School
Status at Exit:
Pre-School
Full-time K-12
Part-time K-12
Alternative School
Home School
GED
Dropped Out
Expelled
Suspended
Withdrawn
Not Yet Enrolled/Not
Applicable/Graduated
Other:_________________
Did this child have to change schools as Yes
a result of the housing placement?
No
Not applicable (no housing placement)
Unknown
Disability Type None
Client Refused
Client Doesn’t Know
at Exit:
Mental Health Physical
Chronic Health
Drug Abuse
Alcohol Abuse
HIV/AIDS
Hearing Impaired
Vision Impaired
Developmental
Other: ____________________________________
Health
Insurance at
Exit:
Updated 3.1.16
None
Client Refused
Medicaid (OHP)
Medicare
Private Pay Health Insurance
Client Doesn’t Know
VA Medical Services
Employer Provided
Other: __________________________
Child (page 1 of 1)
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