SAMPLE PREVENTION & DIVERSION ASSESSMENT TOOL *Adapted from Hennepin County and Columbus YWCA assessment tools

Transcription

1 SAMPLE PREVENTION & DIVERSION ASSESSMENT TOOL *Adapted from Hennepin County and Columbus YWCA assessment tools This assessment tool, based off of Minneapolis/Hennepin County, MN and Columbus, OH s assessment forms, will be of use to communities attempting to determine if a household needs prevention or diversion assistance. This should be administered as soon as a family enters the intake center to determine if they will need shelter or other provisional help or if they can be assisted without having to enter the homeless assistance system. Household Members Adults Name (list primary adult first) Age Gender SSN Race Minor Children Name Age Gender SSN Race HOH has custody? 1

2 Housing Information Where did you stay last night?: With a friend/family member In a shelter In a transitional housing program In a hospital In jail/prison In a juvenile Detention Facility In a hotel/motel In a foster care/group home In a Safe Haven In a substance abuse treatment facility In my own housing rental In my own housing owned In permanent supportive housing In a car, on the street, or in another place not meant for human habitation In other housing Are you safe in your current living situation right now? Is there anyone else you and your family could stay with for at least the next two business days if you were able to receive case management services/transportation assistance/limited financial support? Yes No What is the last address where you had housing in your name? Street Number: City: State: Zip Code: How long were you in your last permanent housing situation? One week or less 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 Housing Crisis Information What brings you here today (check all that apply)? Problems with landlord 2

3 Have rental or utility arrears (circle which): Evicted from a private dwelling or housing provided by family or friends Victim of foreclosure on rental property Doubled up and must leave housing Discharged from an institution in which the head of household was a resident for more than 30 days Living in housing that has been condemned Sudden and significant loss of income Sudden and significant increase in utility or rent costs Accumulated rental and/or utilities arrears Experiencing high overcrowding Violence or abuse occurring in the family s household *If domestic violence is occurring, refer to appropriate DV provider. Other Factors contributing to current housing crisis (circle all that apply): Substance abuse/addiction Divorce Family/personal illness Fire Stay in jail/prison 3

4 Moved to seek work Relationship problems Substandard housing Unemployment Other Homelessness History Have you ever been to a shelter or other homeless assistance program before? If yes, what was the name of the program?: When were you last there? / / Income Household income is at or below 30% of AMI Household income is equivalent to that of households entering shelter ($ ) Has family experienced homelessness in the last 12 months? Case manager/intake worker: If No to all Income questions, explain circumstances that dictate family will become homeless without this assistance. This concludes the assessment. 4

5 Follow-Up Information (Case Manager/Intake Worker Only) 1. Was the household diverted from entering shelter? (If no, skip to Question 2). If yes, to where?: Friend s house Family member s housing Previous housing Other (please describe): How long were they in this housing? (number of days) Did they find permanent housing? Have they come back to shelter/the homeless assistance system since being diverted? Are there whereabouts unknown? 2. Did the household receive prevention assistance? What type? Utility assistance in the amount of $ Rental assistance in the amount of $ Security deposit in the amount of $ Moving costs in the amount of $ Other $ Where do they live currently? Remained in housing Relocated to different permanent housing unit In homeless assistance system Unknown IF remained in previous housing or relocated to different permanent housing situation, how long have they been there? # of Days: 5