Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ 07601

Transcription

1 Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ Housing Authority of Bergen County - Christ Church CDC - Care Plus NJ, Inc. Next Step intake worksheet Interview date: Interviewer: Name: (first, middle, last) Birth Date: Social Security #: How did you hear about Christ Church CDC and the Center? Gender: [ ] male [ ] female [ ] Trans-male [ ] Trans-female Ethnicity: [ ] Hispanic / Latino [ ] Non-Hispanic / Non-Latino Race: How would you describe your race? [ ] Asian [ ] American Indian / Alaskan Native [ ] Native Hawaiian or other Pacific Islander [ ] Black or African-American [ ] Other (list) [ ] White [ ] Don't know Housing status: What is it right NOW? [ ] Homeless [ ] Stably housed [ ] Housed and at risk of losing housing - Date when losing housing: Episodes: (circle one) How many times have you expierenced homelessness (including this time)? or more Homeless Duration: If you are homeless now, how long have you been homeless? [ ] 0-30 days [ ] days [ ] days [ ] Between 6 and 12 months [ ] days [ ] 12 months or longer What agencies do you currently work with? [ ] Bergen County Board of Social Services [ ] Hackensack Human Services [ ] Drug Court [ ] Jail Diversion [ ] Probation [ ] Parole [ ] PATH [ ] ICMS Page 1

2 Monthly Income Sources: Are you receiving [ ] Earned Income $ [ ] Unemployment benefits $ [ ] SSI $ [ ] SSDI $ [ ] Veteran's disability payment $ [ ] Private disability insurance $ [ ] Worker's compensation $ [ ] TANF $ [ ] General public assistance $ [ ] SSA retirement income $ [ ] Veteran's pension $ [ ] Pension from a former job $ [ ] Child support $ [ ] Alimony or spousal support $ [ ] Other (list) $ [ ] None Non-Cash benefits: [ ] MEDICAID health insurance program [ ] SNAP (Food Stamps) [ ] State Children's Health Insurance Program [ ] MEDICARE health insurance program [ ] Veterans' Administration (VA) Medical Services [ ] WIC (Supplemental Nutrition Program) [ ] TANF transportation services [ ] TANF child care services [ ] Section 8, public housing, rental assistance [ ] Other TANF-funded services [ ] Other source [ ] Temporary Rental Assistance [ ] None Special needs detail: Do you currently receive medical care? yes [ ] [ ] no Do you currently receive mental health care? yes [ ] [ ] no Details: Special needs / disabling condition: Yes No Physical disability: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] Developmental disability: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] Chronic health condition: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] HIV/AIDS: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] Mental health: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] Is this a serious problem? [ ] [ ] Substance abuse: [ ] Yes [ ] No Currently receiving services or treatment? [ ] [ ] Drug Alcohol Both Is this a serious problem? [ ] [ ] Victim of Domestic Violence: [ ] Yes [ ] No When: [ ] within past 3 months [ ] 3-6 months ago [ ] 6-12 months ago [ ] more than a year ago Page 2

3 Residence Prior to Program Entry: Where did you stay the last night before you came to the shelter? [ ] Emergency shelter [ ] Living with family member [ ] Transitional housing [ ] Living with friend [ ] Permanent supportive housing [ ] Rented room, apartment, or house [ ] Psychiatric hospital or facility [ ] Owned apartment or house [ ] Substance abuse treatment or detox [ ] Hotel or motel w/o emergency shelter funds [ ] Hospital (non-psychiatric) [ ] Place not meant for habitation (streets/car, etc.) [ ] Jail, prison, or juvenile detention facility [ ] Refused Contact info: Where is your mail delivered? address: city/state/zip: telephone: Last Permanent Address: (city, state, ZIP code) Length of Stay (at permanent address): Last day you lived there (permament address): General Health: How would you describe your general health? [ ] Excellent [ ] Fair [ ] Very Good [ ] Poor [ ] Good [ ] Don t know Currently Pregnant: Due Date: / / [ ] Yes [ ] No Currently Employed: [ ] Yes [ ] No employment: Number of hours worked in past week: Employment Tenure: [ ] Permanent [ ] Temporary [ ] Seasonal Looking for Work (if not currently employed): [ ] Yes [ ] No Homeless Cause: What happened to make you homeless? [ ] Benefits loss/reduction [ ] Illness [ ] Job income loss/reduction [ ] Injury [ ] Eviction [ ] Domestic violence [ ] Relocation [ ] Asked to leave shared residence [ ] Release from Prison/Jail [ ] Drug/Alcohol abuse [ ] Discharge from Hospital [ ] Natural disaster [ ] Discharge from psychiatric facility [ ] Other (list) Page 3

4 Homeless History Homeless since: Brief history: Write a narrative of how this person got to the situation they are in. Use extra pages if needed. Previous Shelter residence: Have you ever stayed in a shelter? Dates of stay: [ ] Peter's Place [ ] Kansas Street Shelter [ ] IRF overflow shelter [ ] Orchard Street "sit-up" shelter [ ] Other Bergen County Shelter [ ] Shelter outside Bergen County Marital Status: [ ] Divorced [ ] Single / Never Married [ ] Separated [ ] Married [ ] Remarried [ ] Common Law [ ] Widow(er) Highest Level of School Completed: [ ] No schooling completed [ ] 11 th grade [ ] Nursery school to 4 th grade [ ] 12 th grade - no diploma [ ] 5 th or 6 th grade [ ] High School Diploma [ ] 7 th or 8 th grade [ ] GED [ ] 9 th grade [ ] [ ] 10 th grade Post-secondary school (any school beyond high school) Received vocational training/apprenticeship certificate: [ ] Yes [ ] No Post Secondary Degree: [ ] None [ ] Doctorate [ ] Associates Degree [ ] Other graduate/professional degree [ ] Bachelor's [ ] Advanced training certificate / skilled artisan [ ] Master's Current Student: [ ] Yes [ ] No Page 4

5 Veteran?: [ ] Yes [ ] Refused [ ] No Individual/Family Type: [ ] Individual Male [ ] Individual Female # of Children: (circle one) #1 #2 #3 #4 #5 #6 #7 #8 #9 Age: Gender: M / F M / F M / F M / F M / F M / F M / F M / F M / F Birthplace: (City, County, State) Citizen: Are you a US citizen? [ ] US Citizen (includes people born in Puerto Rico) [ ] Registered alien [ ] Undocumented alien Alien Registration: What is your immigration #? Primary Language: What is your primary language? [ ] English [ ] Other (list) Services Sought: [ ] Employment [ ] Child Care [ ] Legal aid immigration [ ] Food [ ] Dental Care [ ] Other: [ ] Transportation [ ] Household Goods [ ] Alcohol Treatment [ ] Mainstream Benefits [ ] Shelter/housing [ ] Homeless Prevention/Housing [ ] Mental health care [ ] Drug treatment [ ] Legal aid - CRJS/Civil [ ] Medical Care ID in hand: Do you have a [ ] Green card [ ] Driver's license [ ] Passport (issued by whom) [ ] Non-driver's ID [ ] Social Security card [ ] Other [ ] Birth Certificate Emergency Contact: We will only contact this person in an emergency. Name: Phone: Address Relationship: Page 5

6 Work history: Date(s) Company / Position Page 6

7 Respect Confidentiality Next Step Guidelines & Rules Every guest is expected to respect all Center staff, volunteers, and other guests. Disrespectful behavior will not be tolerated. It is very important to Christ Church CDC that information about guests remains confidential. We may be required to collect some personal informatio by law or by organizations that give us money to operate this program. Other personal information that we collect is important to run our programs, to improve services for people who are homeless, and to better understand the needs of people who are homeless. We only collect information that we consider to be appropriate. Alcohol & Drugs Limited access areas Access to Services Next Step Activities Material Supplies Telephone use Guest information and conversations shared will not be discussed with anyone outside of the Center without written consent. Exceptions will be made if it is necessary to treat an emergency; if it is evident that a guest will harm him/her self or another; if there is reasonable cause to believe that a person has been or will be abused; if a court orders information about a guest. No one may bring alcohol and/or drugs onto the property. A guest may be asked to leave the building if he/she is intoxicated or under the influence of any substance. Guests are not permitted in the kitchen, staff offices or in any area marked "Staff Only," without a Center staff member, service partner, or volunteer present. In order to provide the highest level of service, only active or new guests will have access to Next Step. Guests are welcome to be in the Center for the purpose of working on their next steps, not for resting, socializing or waiting. Solicitating or borrowing money or items or selling of items to staff members or other guests is strictly prohibited. Preaching and/or attempting to convert others is not appropriate. Material suppies such as toiletries and clothing will be provided to guests during Next Step hours and at staff's discretion. CCCDC will make an effort to provide guests with these material services. Decisions will be based on supply, availibility, and the assessment of need. Only guests working on their next steps may use the Next Step phone to make local calls. The phone is not to be used for personal phone calls. Use of directory assistance (411) is not permitted. Please ask a Next Step staff person for internet assistance. Phone calls must be limited to 10 minutes. When staff request that you relinquish the phone, please do so. If you are found making personal calls, you may loose your phone privelages. Shower use Showers are available during Next Step hours and are on a first come first served basis. Showers are limited to 15 minutes and towels and toiletries can be provided. Mail Guests may apply to use the Center address to receive mail. regularly. Unclaimed mail will be returned to the sender. Guests must check their mail Concerns Questions or complaints should be brought to the attention of a staff member. If the client is not satisfied with the staff member's response, the matter may then be discussed with the Program Manager. Guest signature Date Page 7

8 Goals and Next Steps 1) GOAL: MY NEXT STEPS ARE: List Steps Below DONE 2) GOAL: MY NEXT STEPS ARE: List Steps Below DONE 3) GOAL: MY NEXT STEPS ARE: List Steps Below DONE Client signature Date Goals and next steps should be realistic and achievable. Income and identification are necessary to obtain housing. Next Steps will be reviewed periodically. Page 8

9 Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ Housing Authority of Bergen County - Christ Church CDC - Care Plus NJ, Inc. SHELTER WAIT LIST APPLICATION Date: Name: Phone Numbers: [ ] Emergency [ ] Not added at this time Priority level: [ ] Non-emergency [ ] Remove from wait list [ ] Admin review Date Shelter Needed: Priority reason: Completed by: CCCDC approval: For office use: [ ] OK [ ] DNC Program Considerations: Bergen County Resident [ ] yes [ ] no 18 years of age or older [ ] yes [ ] no Distribution conviction within last 6 months [ ] yes [ ] no History of Violence [ ] yes [ ] no Location: Action needed: Page 9

10 Interview date: Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ Housing Authority of Bergen County - Christ Church CDC - Care Plus NJ, Inc. Interviewer: Shelter Application Name: (first, middle, last) Birth Date: Social Security #: Gender: [ ] male [ ] female Last Permanent Address: (city, state, ZIP code) Residence Prior to Program Entry: Where are you living now? [ ] Living with family member [ ] Emergency shelter [ ] Living with friend [ ] Transitional housing [ ] Rented room, apartment, or house [ ] Permanent supportive housing [ ] Owned apartment or house [ ] Psychiatric hospital or facility [ ] Hotel or motel w/o emergency shelter funds [ ] Substance abuse treatment or detox [ ] Place not meant for habitation (streets, car, etc.) [ ] Hospital (non-psychiatric) [ ] Don't know [ ] Jail, prison, or juvenile detention facility [ ] Refused Housing status: NOW [ ] Housed and at risk of losing housing [ ] Homeless when: [ ] Sheltered homeless [ ] Stably housed Special needs detail: Do you currently receive medical care? [ ] yes [ ] no Last Visit? Do you currently receive mental health care? [ ] yes [ ] no Last Visit? Do you currently use alcohol? [ ] yes [ ] no How Often? Do you currently use drugs? [ ] yes [ ] no Details: How Often? What medications are you currently taking/for what reason? Page 10

11 What agencies do you currently work with? [ ] Bergen County Board of Social Services [ ] Hackensack Human Services [ ] Drug Court [ ] Jail Diversion [ ] Probation [ ] Parole [ ] PATH [ ] ICMS Do you have any Adult arrests, charges, and/or convictions in Bergen County? [ ] yes [ ] no Number Latest Date Reason Do you have any adult arrests, charges, and/or convictions in other counties/states? [ ] yes [ ] no Number Latest Date Reason Relationships: Do you have family members in New Jersey? [ ] yes Who? Where? Who? Where? [ ] no Do you have friends in the area? [ ] yes [ ] no Do you have friends or family members staying in or working at the Center? [ ] yes [ ] no For interviewer use only: Did you attach printouts from BCSD website? [ ] yes [ ] no (Print out cover sheet listing all charges of client, but only print out individual charges within past 5 years) [ ] I looked it up, does not have a record Page 11

12 Bergen County Housing, Health and Human Services Center 120 South River Street, Hackensack, NJ Housing Authority of Bergen County - Christ Church CDC - Care Plus NJ, Inc. Date: Name: [ ] is accepted for shelter beginning on [ ] is added to the waitlist for shelter when it becomes available [ ] is added to the waitlist for shelter pending administrative review If you are on the waitlist you must: 1 call the shelter line, , regularly and leave a message saying that you still need shelter. Include your name and telephone number where you can be reached. 2 if you do not have a phone, stop by Next Step any day from 9:30-11:00 am or 1:00-4:00 pm. Tell the person at the desk that you are on the waiting list and need shelter. Ask them to write your name on the shelter call list. NOTE: 3 Call or stop by at least twice a week If we do not hear from you for 10 days, we will assume you have found shelter and will remove your name from the waiting list. Further Instructions/Other Notes: Page 12