Unified Supportive Housing System Vulnerability Assessment
Email address *
Unified Supportive Housing System Vulnerability Assessment
Please read the OBSERVATION ONLY questions carefully.
Client's First Name, First Letter of Last Name and CSP# (Example: Yolanda Z. #123456) *
Your answer
1. In the past three months, how many times have you been to the emergency department/room? *
2. In the past six months, how many times have you taken an ambulance to the hospital? *
3. In the past six months, how many times have you used a crisis service, including distress centers and suicide hotlines? *
4. In the past year, how many times have you hospitalized as an inpatient? *
5. In the past six months, how many of your encounters with police resulted in a jail or prison stay? *
6. In the past 12 months where have you resided most frequently? *
7. Do you currently have Kidney disease/ End Stage Renal Disease or Dialysis? *
8. Do you currently have Liver Disease, Cirrhosis, Hepatitis C or End-Stage Liver Disease? *
9. Are you currently Pregnant? *
10. Do you have a permanent physical disability that limits your mobility? (i.e., wheelchair, amputation, unable to climb stairs) *
11. Do you currently have Cancer? *
12. If "yes" to any of the above, is medical condition under treatment? *
13. OBSERVATION ONLY_Interviewer, if client said "No" to questions 7-11, do you observe signs or symptoms of serious health conditions? *
14. Do you currently have problematic drug or alcohol use, abuse drugs or alcohol or been told that you do? *
15. Have you consumed alcohol almost every day for the past month? *
16. Do you currently use injection drugs or shots? *
17. Have you ever been treated for drug or alcohol problems and returned to drinking or using drugs within the past 6 months? *
18. OBSERVATION ONLY_Interviewer, if the client said "no" questions 14-17, do you observe signs or symptoms of problematic alcohol or drug abuse? (Deterioration in functioning, cognitive damage, lack of self-care or active use.) *
19. Have you ever been diagnosed with a mental health issue? *
20. Are you currently receiving or have you ever received treatment for mental health reasons? *
21. Have you had a serious brain injury or head trauma that required hospitalization or surgery? *
22. Have you been diagnosed with a learning or developmental disability? *
23. OBSERVATION ONLY_Interviewer, if the client said "no" to questions 19-22, do you observe signs of confusion, evidence of developmental disability, dementia, or memory impairment? (Self-talk, distracted, paranoia, fear, phobic, depressed or manic) *
24. As a minor were you ever in foster care or abused or neglected by caregivers? *
25. Did you leave your last living situation due to violence from an intimate partner? *
26. OBSERVATION ONLY_Interviewer, do you observe signs of problematic social behavior? (Responds in angry, profane, obscene or menacing verbal ways, intimidating, impaired ability to deal with stress, no apparent social network, difficulty engaging positively with others) *
27. Do you have any friends, family, or other people in your life you can count on? *
28. OBSERVATION ONLY_ Interviewer, do you observe signs of Prospective Applicant not being able to meet basic needs? (Poor hygiene/ clothing, unable to access food on own or no insight on needs) *
29. How do you get money? *
A copy of your responses will be emailed to the address you provided.
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