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AL BALANCE OF STATE CONTINUUM OF CARE ( AL -507)
COORDINATED ACCESS FORM AL -507
  1. Please enter interviewer's First and Last name.

  2. Name of organization conducting the Assessment, address and phone number.

  3. Please enter the county where the person you are interviewing is staying.
  4. Name of person being assessed.

  5. Contact number. If the person being assessed does not have a phone, enter the name and the number of a person with the telephone who can contact the assessed person.

  6. Address of person being assessed

  7. Where did the person spend the night last night?

  8. What is your gender?
      male
      Female
      Transgender
  9. What is your date of birth?

  10. Does the person consider himself or herself to be Hispanic/Latino?
      Yes
      no
      Refused to Answer
  11. What race does the person consider himself or herself? If multi-racial, check other and enter race.

  12. Are you alone or with other family members?
    1. Is the assistance needed for an individual or a household?
        an individual (if individual go to the next question)
        family/household (if assistance is for a family continue with this question)
    2. How many people are in the household?

      Enter a numeric response.
    3. List name, birth date, relationship, gender and race of other family members.

  13. Is person or family being evicted for non-payment or rent? If yes, go to question 18.
      Yes
      No
      Not Applicable
  14. How long have you been without housing this time?
  15. Including this time, how many times have you been homeless in the past 3 years?
  16. In the last three years, Have you been homeless for at least 12 months?
      Yes
       No
       Don't know
       Refused
  17. Where was your last Permanent address? Get city, state and zip code if possible.

  18. 18. Have you ever received, or are you currently receiving, treatment services for a Mental Illness?
       Yes
       No
       Refused/Don't know
  19. Have you ever received, or are you currently receiving, treatment services for a Substance Abuse?
       Yes
       No
       Refused/don't know
  20. Have you ever received, or are you currently receiving, treatment services for a HIV/AIDS?
      Yes
       No
       Refused/Don't know
  21. Have you ever received, or are you currently receiving, treatment services for a long term physical disability?
      Yes
      No
      Refused/Don't know
  22. Have you ever received, or are you currently receiving, treatment services for a Developmental Disability?
      Yes
      No
      Refused/Don't know
  23. Have you ever received, or are you currently receiving, treatment services for a Chronic Health Condition?
      Yes
      No
      Refused/Don't know
  24. Does the person receive SSI/SSDI or other compensation as a result of this disability?
      Yes
      No
      Not applicable
      Don't Know
      Refused
  25. Would the person like to apply for SSI/SSDI?
  26. Does household receive income?
      Yes
      No
      Don't Know refused
  27. If household receives income, from what source and how much? This may be answered with an hourly, weekly, monthly or annual amount and stated as such. If no income enter 0 (zero).

  28. Is homelessness a result of abuse in the home or other abuse you are trying to escape from (Ex: human trafficking)? ?
      Yes
      No
      Refused/Don't know
  29. Has person ever been a victim of domestic violence or human trafficking?
      Yes
      No
      Refused/Don't know
  30. Has person ever stayed in a domestic violence shelter?
      Yes
      No
      Refused/Don't know
  31. Has person ever served in the U. S. Military? (including National Guard, Coast Guard, Air Force, Army, Navy, Marines or reserves)
      Yes
      No
      Refused/Don't know
  32. Was person ever called into active duty?
      Yes
      No
      NA
      Refused
  33. Notes:

  34. Date of original assessment

  35. Date received in ARCH office

  36. Date ARCH was first contacted

  37. For internal use only Is this individual or family chronically homeless
      Yes
      No
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