CES Survey - LAHSA Documents

Greater Los Angeles
Coordinated Entry System
Survey Packet
Version 1.1
CES Survey: Introduction
Thank you for taking time to know the name and needs of our homeless neighbors. The 20-30 minutes you will spend are
invaluable to helping us understand the unique needs of the respondent and also the broader region in which he/she
resides. Your engagement of the respondent and effective application of the following survey is a critical first step to
ending homelessness in Greater Los Angeles. Thank you!
CONTENTS
1. Instructions (for Surveyor): Brief guidelines for best application of this survey - further instructions are available
electronically on the CES Website @ www.HomeForGoodLA.org/ces (VI-SPDAT Manual & Webinar) and inperson via periodic trainings.
2. Checklist: A list of the steps involved in making the respondent eligible for referrals through CES.
3. Instructions (for Respondent): A script of instructions to be read aloud to the respondent.
4. Consent: Required form to gain legal permission to share respondent answers in the shared database.
5. Part 1 (VI-SPDAT & Intake)
Part 1 of the CES Survey features the Vulnerability Index-Service Prioritization Decision Assistance Tool (VISPDAT). The VI-SPDAT is a triage tool designed to recommend the best type of permanent housing solution for
someone experiencing homelessness. It is a holistic survey developed by OrgCode Consulting and Community
Solutions and is written in a manner designed to be understood more easily by respondents. Part 1 of the survey
also includes a set of basic intake and eligibility questions to help begin identifying resources and supports that
the respondent may qualify for immediately.
6. Part 2 (Housing Preferences)
Part 2 of the CES Survey completes the set of eligibility questions that are used to help make more appropriate
referrals to housing opportunities. This was formerly known as the Matching Initiation Form. While you may
choose to complete this portion with the respondent at a later time, many of the permanent housing resources
available through CES require both Parts 1 & 2 (along with document collection) to be complete before referrals
are generated.
7. Contact Sheet: A sheet with follow-up contacts that you may wish to provide the respondent upon request.
8. Additional Consents (*If Provided): Additional authorization, release and consent forms may be provided by
your agency or coordinator to allow for seamless coordination with other supports or resources.
INSTRUCTIONS FOR THE SURVEYOR **Please do not read aloud**
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THE CONSENT MUST BE COMPLETED AND SIGNED (FOR HOUSEHOLDS, EVERY ADULT MEMBER MUST SIGN)
In the case that respondent refuses consent, you may still proceed, however please note these special
instructions: Do not enter Personal Identifiable Information (PII) into HMIS. HMIS will automatically generate an
anonymous ID. Please retain at least the first page of CES Survey Part I (with HMIS ID & Client Name) for your
records and future matches since you will not be required to enter identifying information into HMIS.
DO NOT BE DISAPPOINTED IF THE RESPONDENT DOESN’T WANT TO BE SURVEYED.
Negative experiences with past services may cause the respondent to be distrustful. Reversing course on that is a
process, and your positive interaction and respect of their boundaries will help future engagements.
DO NOT PROMISE HOUSING OR SERVICES.
Though you may be trying to be helpful, false promises will only add to their distrust and disinterest with future
engagements.
Version 1.1
Introduction: Page 1 of 3
Modified 3/19/2015
CES Survey: Introduction
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DO NOT MANIPULATE RESPONSES.
Major eligibility criteria are officially verified later so it does not benefit the respondent to be dishonest. Also,
don’t be concerned if the respondent isn’t noting some issues that are clearly visible - the “Observation”
questions will balance the responses for several sections.
DO NOT VOLUNTEER THE SCORE OR THE SCORING PROCESS.
You may share the general housing recommendation, but we do not want people being referred to as numbers.
YES AND NO ANSWERS ARE FINE, IDEAL EVEN. AVOID FOLLOW UP QUESTIONS.
Respondents do not need to explain themselves. Explain questions if further clarification is needed, but try to
keep the conversation short and clear to respect their time. Make note of items you may want to come back to,
but allow engagement/case management to happen separate from the survey itself.
COUNT BACKWARDS AND PAUSE.
For any question that asks a date range, count backward to the first date – so if today is January 1, 2015 and the
questions asks “in the last 6 months,” say in “in the last 6 months…December, November, October, September,
August, July. So since July 2014 …” Also, for any question that states “anything like that,” add an intentional
pause between “or anything (pause) like (pause) that” to help emphasize that you have read a list.
BE PREPARED TO EXPLAIN LENGTH OR QUESTIONS
If a respondent finds a question offensive or is frustrated by the length, please explain that each question will
help to avoid some inappropriate referrals and hopefully save them time in the long run. For other questions with
more obvious answers, you may explain that you wanted to give them the ability to speak for themselves.
PRACTICE.
As you become more comfortable with the survey, you should notice a gradual reduction in the amount of time it
takes to complete.
CHECKLIST
Prepare
 Review: Instructions for the Surveyor
 Read Aloud: Instructions for the Respondent
 Request Signature: Consent Form
Survey
 Verbally Administer: Survey Part 1 (VI-SPDAT & Intake)
 Verbally Administer: Survey Part 2 (Housing Preference)
Survey Part 1 and 2 may be completed at separate times; however, both are needed to complete a client record.
 Take picture: Client may decline. Ask if you can take a picture of their ID instead or take a picture with them.
 Provide: Contact sheet if you or your coordinator are willing to be available for follow-up contact
Follow-Up
 File Consent: Keep record of consent and/or distribute to appropriate party in your SPA
 Data Entry: Enter survey responses into HMIS
 Upload: client picture, copies of documents, additional signed consents, to HMIS
================The following steps may be taken over by a Housing Navigator=======================
 Obtain Documents (*if not already in possession): Birth Certificate, ID & Social Security. Although not
immediately required, please be prepared to quickly prepare income verification documents as well.
Possessing documents required for housing is the final step in becoming “match-ready” for most housing in CES.
 Data Entry: Note receipt of documents and upload scanned copy of documents into HMIS if possible.
Version 1.1
Introduction: Page 2 of 3
Modified 3/19/2015
CES Survey: Introduction
INSTRUCTIONS FOR RESPONDENT
Hello! My name is ______________ and I am with a group called_______________ (organization name). I have a survey
I would like to complete with you.
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There are two parts to this survey, and it’ll take about 25-30 minutes to complete.
Most questions only require a “yes,” “no” or other one-word answer. If you have more to share about an
answer, I’d be happy to discuss that after the survey, but it’s important that we finish this first.
While this is not a housing application, the answers will help us understand your health and housing needs and
the needs of our community, and may help us make better referrals for you in the future.
All that to say, I’m not using the answers you give to make any personal judgments about you.
This survey is for anyone who is experiencing homelessness – not just people with a certain type of need.
Some questions are personal in nature, but again, every question is designed to help us help you. You can skip or
refuse any question that you don’t feel comfortable answering, but the more questions you’re willing to answer,
the better.
Someone may follow up with you to assist in getting documents needed to access resources, so it’s important
that we have accurate contact information for you.
There is no need to take this survey twice, but from time to time we may want to update it with you, to make
sure the information is accurate.
Afterward, you may request a contact sheet and refer to it if you have questions.
Before we begin, I need to get your permission to do this survey with you. Please review the following form
and let me know if you have any questions.
Version 1.1
Introduction: Page 3 of 3
Modified 3/19/2015
CES Survey: Consent
Los Angeles & Orange County Homeless Management Information System (LA/OC HMIS)
Collaborative and Participating Organizations
Client Consent to Provide and Disclose Information
________________________________________________________________________________________
The LA/OC Homeless Management Information System (HMIS) is a local electronic database that securely
records information (data) about clients accessing housing and homeless services within the Los Angeles and
Orange Counties. This organization participates in the HMIS and shares information with other organizations
that use this database. This information is utilized to provide supportive services to you and your household.
What type of information may be shared in the HMIS?
We collect general and Protected Personal Information about you. This includes but is not limited to:
 Your name and your contact information
 Your social security number
 Your birthdate
 Your basic demographic information such as gender and race/ethnicity
 Your history of homelessness and housing (including your current housing status and where and when
you have accessed services)
 Your self-reported medical history including any mental health and substance abuse issues
 Your case notes and services
 Your case manager's contact information
 Your income sources and amounts; and non-cash benefits
 Your veteran status
 Your disability status
 Your household composition
 Your emergency contact information
 Any domestic violence history
 Your photo, if you choose to provide
How do you benefit from providing your information?
The information you provide for the HMIS helps us coordinate the most effective services for you and/or your
family. By sharing your information, you may be able to avoid being screened more than once, get faster
services, and minimize how many times you have to tell your ‘story.’ Collecting this information also gives us a
better understanding of homelessness in your local area and the effectiveness of the services provided in your
area.
Who can have access to your information?
The LA/OC Collaborative organizations and other participating organizations can have access to your data.
These organizations may include homeless service providers, other social services organizations, housing
groups, and healthcare providers. All participating organizations who have access to your information have
signed an agreement to maintain the security and confidentiality of your information.
How is your personal information protected?
Your information in the HMIS is protected by passwords and encryption technology. In addition, each
participating organization must sign an agreement to maintain the security and confidentiality of the
information. Any person or participating organization that violates the agreement may have their access rights
terminated and may be subject to further penalties.
Version 1.1
Consent: Page 1 of 2
Modified 3/19/2015
CES Survey: Consent
By signing below, you understand that:
 You have the right to receive services even if you do not sign this consent form.
 Your consent permits any participating organization to update your information in HMIS without asking
you to sign another consent form.
 You may cancel your consent at any time, but your cancellation must be done either in writing or by
completing the Client Revocation of Consent to Provide and Disclose Information form. Upon receipt of
your revocation, the Protected Personal Information that you previously authorized to be placed in the
HMIS will be de-identified.
 The LA/OC HMIS Privacy Notice contains more detailed information about how your information may
be used and disclosed.
 Upon your request, we will provide you with:
o A copy of this form
o A copy of the LA/OC HMIS Privacy Notice
o A copy of your HMIS records within five (5) business days of your request
o A current list of participating organizations that have access to your data
 Aggregate or statistical data that is released will not disclose any of your Protected Personal
Information.
 This consent is valid for seven (7) years from the date you sign below
 You have the right to file a grievance against any organization whether or not you sign this consent
 You are not waiving any rights protected under Federal and/or California law
SIGNATURE AND ACKNOWLEDGEMENT
Your signature below indicates that you have read (or been read) this client consent form, have received
answers to your questions, and you freely consent to have your information, and that of your minor children (if
any), entered into the LA/OC HMIS. You also consent to share your information with other organizations as
described on page one of this form.
Client Name: ________________________
DOB: _____________ Last 4 digits of SS_________
Signature ___________________________________________
Date ______________________
Head of Household (Check here)
Minor Children (if any):
Client Name: ________________________
DOB: _____________ Last 4 digits of SS_________
Client Name: ________________________
DOB: _____________ Last 4 digits of SS_________
Client Name: ________________________
DOB: _____________ Last 4 digits of SS_________
Client Name: ________________________
DOB: _____________ Last 4 digits of SS_________
____________________________________________
Print Name of Organization
_______________________________
Print Name of Organization Staff
____________________________________________
Signature of Organization Staff
_______________________________
Date
Version 1.1
Consent: Page 2 of 2
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Instructions for Respondent: PLEASE READ ALOUD
The first part of this survey will help us learn more about you, your situation, and your needs.
Again, I know that some people tell others what they want them to hear, rather than telling them the truth. It’s up to you, but the more
honest you are, the better we can figure out how best to support you. Also, keep in mind that since eligibility requirements will be
verified later, it’s best to answer as honestly as you can.
If at any point you don't understand what I am asking, just let me know. I’ll give you a moment to gather your thoughts, and we’ll get
started with the first question...
**wait 15 seconds before proceeding** (even though this is awkward, this will help the respondent mentally prepare)
Identification (All fields required unless otherwise noted)
First Name: ___________________________________
Middle Name (Optional): _____________________________________
Last Name: ___________________________________
Suffix (Optional): _____
Name Data Quality:
Did the client provide their full
name?
 Full Name Reported
 Partial, street name, or code
name reported
 Client Doesn’t Know
 Client Refused
 Data not Collected
Date of Birth:
________/________/________
 Full DOB reported
 Approximate or partial DOB
reported
 Client Doesn’t Know
 Client Refused
 Data not Collected
HMIS consent signed?  Yes  Refused
Physical Description (Optional): Last Known Permanent Address:
Where have you last lived for 90 days or more?
(Not including emergency shelters and transitional housing)
Address:
City:
County:
SSN:
State:
_________-_______-__________
 Full SSN reported
Zip:
 Approximate or partial SSN
reported
 Client Doesn’t Know
Address
 Client Refused
Quality:
 Data not Collected
__________
 Full Address Reported
 Client Doesn’t Know
 Incomplete or Estimated  Client Refused
Address Reported
 Data not Collected
Contact Information (Optional but extremely helpful)
Phone Number (Do you have a number and email where I can
follow-up with you or leave a message?)
Main: (______)______-_________ x______  Leave message
Alternate:(______)______-_________ x______  Leave message
Email
Version 1.1
[email protected]____________
Phone Type
 Home
 Cell
 Home
 Cell
Contact Preference
 Work
 Message Center
 Work
 Message Center
 Phone
 Text
 Email
Notes
Survey Part 1: Page 1 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Contact Type
Alternate Contact
(Who is the best person to get in
touch with you?)
Relationship: _______________
First Name: _______________
Last Name: _______________
Emergency Contact
(In case of an emergency, who
should we alert?)
 Same as above
Relationship: _______________
First Name: _______________
Last Name: _______________
Phone Number
(______)______-_________ x______
(______)______-_________ x______
Client Name / HMIS ID: _____________________
Phone Type
Email
 Home
 Cell
 Work
 Message Center
 Home
 Cell
 Work
 Message Center
Location Information (Optional)
Location Type:
On a regular day, where is it easiest to find you?
 Street
 Vehicle
 Abandoned building
 Bus/train/subway station/airport
 Drop in center
 Day services center
 Soup kitchen
 Emergency Shelter
 Transitional Housing
 Permanent Housing
 Clinic/Hospital - Health
 Clinic/Hospital – Mental Health
 Clinic/Hospital – Substance Abuse
 Jail, prison, or juvenile detention facility
 Family or friend’s room, apartment, condo, or house
 Foster care or group home
What times of day could we find
you there? (Select all that apply)
Address Type
(Enter one: Address, Intersection, or Landmark):
Address:
Intersection:
and
Landmark:
____________________________________________
City, County, State, and Zip (Enter all):
City:
County:
State:
Zip:
Zip Quality:
 Early morning (6am – 9 am)
 Late morning (9am – 12pm)
 Early afternoon (12pm-2pm)
__________
 Full or Partial
 Client Doesn’t Know
 Late afternoon (2pm – 4pm)
 Early evening (4pm – 6pm)
 Evening (6pm – 12 am)
 Client Refused
 Data not Collected
 Overnight (12 am-6am)
 Client Doesn’t Know
 Client Refused
Outreach Contact Details (For outreach programs only, all fields required unless otherwise noted)
Staff Name
Contact Date/Time Program
# of Clients
Notes
(use case note section at end)
SURVEYOR ONLY – DO NOT ASK: Was the client referred to you, or were you requested to contact the client?
Referral Information (Required only for referred clients and requests)
Date & Time
Referral First Name
Referral Type
 Phone
 Email
 Walk-In Referral Last Name
Referral Source
Email
Referral Organization
Phone
Version 1.1
Survey Part 1: Page 2 of 19
 Yes
 No
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Demographics (All fields required unless otherwise noted)
Housing Status:
 Category 1 - Homeless
 Category 2 – At Imminent Risk of Losing Housing (within 14 days or less)
 Category 3 – Homeless only under other Federal Statutes
 Category 4 – Fleeing Domestic Violence
 At Risk of Homelessness
 Stably Housed
TB Clearance Date (Optional)
Ethnicity
 Non-Hispanic
Gender:
 Male
 Client Doesn’t Know
 Female
 Client Refused
 Transgender Female to Male
 Data not Collected
 Transgender Male to Female
 Other (Specify:_________________________)
Have you ever served What is the highest level of education you’ve completed? Race
in the U.S. Military?
(Check All that
(Veteran)
Apply)
 Yes*
 No
 Client Doesn’t Know
 Client Refused
 Data not Collected
*If yes, please administer
VA release of information
 Hispanic
Residency Status
 Citizen
 Permanent Legal Resident
Version 1.1
 Client Doesn’t Know
 Client Refused
 Data not Collected
Clinic Providing Clearance (Optional)
Relation (to Head of Household completing survey)
 Self (Head of household/not part of household)
 Head of Household’s Child
 Head of Household’s Spouse or Partner
 Head of Household’s other Relation Member
 Other: Non-relation Member (i.e. unrelated)
Are you disabled?
(Physical,
Developmental,
Mental Health,
Chronic Health
Condition, HIV/AIDS,
and/or Substance Use
Disorder.)
 Yes
 No
 Client Doesn’t Know
 Client Refused
 Data not Collected
Family Type:
 Unaccompanied
 Single Parent
 Two Parents
 Adults No children
 No Schooling Completed
 Nursery School to 4th Grade
 5th or 6th Grade
 7th or 8th Grade
 9th Grade
 10th Grade
 11th Grade
 Data not Collected
 12th Grade, no diploma
 High School Diploma
 GED
 Post-Secondary School
 4-year College Degree
 Graduate School
 Unknown
 Client Doesn’t Know
 Asylee, Refugee, or other Eligible Immigrant
 Ineligible Immigrant
Survey Part 1: Page 3 of 19
 Asian
 Black or AfricanAmerican
 Native Hawaiian
or Other Pacific
Islander
 American Indian
or Alaska Native
 White
 Client Refused
 Client Doesn’t Know
 Client Refused
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Income and Insurance (All fields required unless otherwise noted)
DPSS ID (Optional): ________________
 GAIN Participant (Optional)
Income Source (Check all that apply):
Stated Income: Pay Interval: How often do you get it?
What sources of income do you have? If you received How much do
Every Twice
housing, how would you pay for things like food and
you get?
Weekly Other
A
Monthly Quarterly Yearly
utilities?
Week Month
$
 No financial resources
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
$
 Earned Income (employment wages / cash)

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


$
 Unemployment Insurance






$
 Supplemental Security Income (SSI)






$
 Social Security Disability Income (SSDI)






$
 VA Service-Connected Disability Compensation






$
 VA Non-Service-Connected Disability Pension






$
 Private Disability Insurance






$
 Workers Compensation






 Temporary Assistance for Needy Families (CalWorks) $






$
 General Assistance (GA) / General Relief (GR)






$
 Retirement Income from Social Security






$
 Pension or retirement income from a former job






$
 Child Support






$
 Alimony and other spousal support






$
 Other Source (Specify:_____________________)






 Client Doesn’t Know
 Client Refused
 Data not Collected
Income Documentation (Optional): Do you have documents that verify those amounts?
Comments (Optional):
 GR Form
 CalWORKs Form
 Pension Letter/Stub
 Pay Stub
 Unemployment Insurance Forms  Unemployment Forms
 Utility Allowance
 W-2 Forms
 Self Declaration
 Child Support Forms  SSDI Form
 Employer Printout/Letter
 Social Security Forms  Workmans Comp
 VA Documentation
 SSI Forms
 Self Employment Docs
Non-Cash Benefits (Check all that apply): What non-cash benefits do you receive?
 None
 Client Doesn’t Know
 Client Refused
 Food Stamps (CalFresh)
 CalWorks Child Care
 Temporary Rental Assistance
Amount: __________
 CalWorks Transportation
 Section 8 or Rental Assistance
 WIC
 Other CalWorks-Funded Services  Other ___________________
Health Insurance (Check all that apply):
 No Health Insurance
 Client Doesn’t Know
 MEDICAID
 MEDICARE
 Employer Provided Health Ins.
 COBRA Health Ins.
 Client Refused
 State Children’s Health Ins.
 Private Pay Health Ins.
Health Insurance Provider (Check all that apply):
 HealthNet
 Anthem Blue Cross
 Kaiser Permanente
 L.A. Care
 L.A. Care Health Plan  L.A. Care Health Partners
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Survey Part 1: Page 4 of 19
 VA
 Care 1st Health Plan
 Data not Collected
 Medically Needy
Amount: _________
 Data not Collected
 VA Medical Services
 MediCal
 Other
 Unknown
 None
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Documentation (Optional)
(Check all that are in the client’s possession)
Expiration Date:
(If applicable)
 Birth Certificate
 Certificate of Disability
 DD214 (Veterans Only)
 Driver’s License / CA ID
 Homeless Verification
 Proof of Residency
 Reference Letter
 Social Security Card
 TB Certification
 Verification of Income
 VA Release
 LACDMH 677 Authorization Consent
 DHS Pre-release
 Other:
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Survey Part 1: Page 5 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Program Entry (All fields required unless otherwise noted)
Program Name: ________________________________________
Consent: System
Program Entry Date: _____/_____/_____
Case Manager: ________________________________
HOMELESSNESS - Adults aged 18 and older and Head of Household < 18 years old, required questions are shaded
Question
1. Where did you sleep last night?
Check One Answer
Comments
 Emergency shelter
 Foster care home or foster care group home
 Hospital or other residential non-psychiatric medical facility**
 Hotel or motel paid for with emergency shelter voucher
 Hotel or motel paid for without emergency shelter voucher
 Jail, prison or juvenile detention facility**
 Long-term care facility or nursing home
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons
 Place not meant for habitation (street, car, bus, riverbed, etc)
 Psychiatric hospital or other psychiatric facility**
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH housing subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other (non-VASH) ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living in a family member's room, apartment, or house
 Staying or living in a friend’s room, apartment or house
 Substance abuse treatment facility or detox center**
 Transitional housing for homeless persons
 Other (Specify:_______________________________________)
 Client Doesn't Know
 Client Refused
 Data not Collected
2. How long have you been staying at the
 One day or less**
 More than three months, but
place where you slept last night?
less than one year
 Two days to one week**
(How long was your stay?)
 One year or longer
 More than one week, but
less than one month**
 Client Doesn't Know
 One to three months**
 Client Refused
 Data not Collected
If question #2 was answered as three months or less (**) AND question #1 was answered as one of the following (**):
-“Hospital or other residential non-psychiatric medical facility”
-“Jail, prison or juvenile detention facility”
-“Psychiatric hospital or other psychiatric facility”
-“Substance abuse treatment facility or detox center”
Then the following question is required:
2a. Where were you sleeping prior  Emergency shelter
to entering the institutional setting
 Foster care home or foster care group home
mentioned above (in question #1)?  Hospital or other residential non-psychiatric medical facility
 Hotel or motel paid for without emergency shelter voucher
 Jail, prison or juvenile detention facility
Continued on Next Page 
Version 1.1
Survey Part 1: Page 6 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
 Long-term care facility or nursing home
 Owned by client, no ongoing housing subsidy
 Owned by client, with ongoing housing subsidy
 Permanent housing for formerly homeless persons
 Place not meant for habitation
 Psychiatric hospital or other psychiatric facility
 Rental by client, no ongoing housing subsidy
 Rental by client, with VASH housing subsidy
 Rental by client, with GPD TIP subsidy
 Rental by client, with other (non-VASH) ongoing housing subsidy
 Residential project or halfway house with no homeless criteria
 Safe Haven
 Staying or living in a family member's room, apartment, or house
 Staying or living in a friend’s room, apartment or house
 Substance abuse treatment facility or detox center
 Transitional housing for homeless persons
 Other
 Client Doesn't Know
 Client Refused
 Data not Collected
3. Have you been continuously homeless
 No
 Client Doesn’t Know
for at least one year?
 Yes
 Client Refused
 Data not Collected
4. In the past three years, how many times
 0 (not homeless - Prevention only)
 Client Doesn’t Know
have you been housed then homeless
 1 (homeless only this time)
 Client Refused
again?
2
 Data not Collected
(How many times have you been homeless  3
in the past three years?)
 4 or more**
If question #4 was answered as “4 or more” (**), then the following question is required:
4a. Total number of months
0
7
 Client Doesn’t Know
homeless in the past three years?
1
8
 Client Refused
2
9
 Data not Collected
3
 10
4
 11
5
 12
6
 More than 12 months
5. How many months have you been
homeless during this current period of being
homeless? (Total number of months
____________ Months
continuously homeless immediately prior to
today)
6. STAFF ONLY – DO NOT ASK: Has the  Yes
client’s homeless status been verified?
 No
(Status Documented)
HISTORY OF HOUSING & HOMELESSNESS - VI-SPDAT, required questions are shaded
Question
7. How many months have you lived on the
streets or in shelters? (in total during lifetime)
Version 1.1
Comments
________ Months
Survey Part 1: Page 7 of 19
 Client Doesn’t Know
 Client Refused
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
RISKS - VI-SPDAT, required questions are shaded
SCRIPT: I am going to ask you some questions about your interactions with health and emergency services. If you need any help
figuring out when six months ago was, just let me know.
Question
Check One Answer (*when applicable)
Comments
8. In the past six months, how many times have
 Client Doesn’t Know
________
you been to the emergency department/room?
 Client Refused
 Client Doesn’t Know
9. In the past six months, how many times have
________
you had an interaction with the police?
 Client Refused
10. In the past six months, how many times
 Client Doesn’t Know
have you been taken to the hospital in an
 Client Refused
________
ambulance? *Please note that this includes
psychiatric facilities as well.
11. In the past six months, how many times
 Client Doesn’t Know
have you been hospitalized as an in-patient,
 Client Refused
________
including hospitalizations in a mental health
hospital?
12. In the past six months, how many times
 Client Doesn’t Know
have you used a crisis service, including
________
 Client Refused
distress centers or suicide prevention hotlines?
13. Have you been attacked or beaten up since  No
 Client Doesn’t Know
becoming homeless?
 Yes
 Client Refused
 No
 Client Doesn’t Know
14. Have you threatened to or tried to harm
yourself or anyone else in the last year?
 Yes
 Client Refused
15. Do you have any legal stuff going on right
 No
 Client Doesn’t Know
now that may result in you being locked up or
 Yes
 Client Refused
having to pay fines?
16. Does anybody force or trick you to do things  No
 Client Doesn’t Know
that you do not want to do?
 Yes
 Client Refused
17. Ever do things that may be considered to be  No
 Client Doesn’t Know
risky like exchange sex for money, run drugs for  Yes
 Client Refused
someone, have unprotected sex with someone
you don’t really know, share a needle, or
anything like that?
18. I am going to read types of places people
 Shelter
 Client Doesn’t Know
sleep. Please tell me which one that you sleep
 Street, Sidewalk or Doorway  Client Refused
at most often. (Check only one.)
 Car, Van or RV
 Bus or Subway
 Beach, Riverbed or Park
 Other (specify in comment)
SOCIALIZATION & DAILY FUNCTIONS - VI-SPDAT, required questions are shaded
Question
19. Is there anybody that thinks you owe them
money?
20. Do you have any money coming in on a
regular basis, like a job or government benefit
or even working under the table, dumpster
diving or bottle collecting, sex work, odd jobs,
day labor, or anything like that?
Version 1.1
Check One Answer
 No
 Yes
 Client Doesn’t Know
 Client Refused
 No
 Yes
 Client Doesn’t Know
 Client Refused
Survey Part 1: Page 8 of 19
Comments
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
21. Do you have enough money to meet all of
your expenses on a monthly basis? Do you
have enough to cover what you need each
month?
22. Do you have planned activities each day
other than just surviving that bring you
happiness and fulfillment?
23. Do you have any friends, family or other
people in your life out of convenience or
necessity, but you do not like their company?
24. Do any friends, family or other people in
your life ever take your money, borrow
cigarettes, use your drugs, drink your alcohol, or
get you to do things you really don’t want to do?
25. OBSERVATION ONLY – DO NOT ASK:
Surveyor, do you detect signs of poor hygiene
or daily living skills?
Client Name / HMIS ID: _____________________
 No
 Yes
 Client Doesn’t Know
 Client Refused
 No
 Yes
 Client Doesn’t Know
 Client Refused
 No
 Yes
 Client Doesn’t Know
 Client Refused
 No
 Yes
 Client Doesn’t Know
 Client Refused
 No
 Yes
WELLNESS - VI-SPDAT, required questions are shaded
Question
Comments
26. Where do you usually go for healthcare or
when you’re not feeling well? (Check all that
apply; answer may come up later in DHS quest)
 Hospital
 Clinic
 VA
 Other (specify in comments)
 Does not go for care
 Client Doesn’t Know
 Client Refused
26a. What is the name of that place?
(Again, answer may come up later too)
_______________________
 Client Doesn’t Know
 Client Refused
SCRIPT: Do you have now, have you ever had, or has a healthcare provider ever told you that you have any of the following
medical conditions:
Question
Check One Answer
 No
 Client Doesn’t Know
27. Kidney disease/End Stage Renal Disease or Dialysis
 Yes
 Client Refused
 No
 Client Doesn’t Know
28. History of frostbite, Hypothermia, or Immersion Foot
 Yes
 Client Refused
 No
 Client Doesn’t Know
29. Liver disease, Cirrhosis, or End-Stage Liver Disease
 Yes
 Client Refused
 Client Doesn’t Know
30. Have you been diagnosed with AIDS or have you tested positive  No
 Client Refused
for HIV?
 Yes**
 Data not Collected
If question #30 was answered as “Yes” (**), then the following questions are required:
 Client Doesn’t Know
30a. Do you expect this to substantially impair your ability
 No
 Client Refused
to live independently?
 Yes
 Data not Collected
30b. Do you have documentation of the disability and
 No
severity on file?
 Yes
 Client Doesn’t Know
30c. Are you currently receiving services or treatment for
 No
 Client Refused
this condition?
 Yes
 Data not Collected
Version 1.1
Survey Part 1: Page 9 of 19
Comments
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
31. History of Heat Stroke/Heat Exhaustion
32. Heart disease, Arrhythmia, or Irregular Heartbeat
33. Emphysema
34. Diabetes
35. Asthma
36. Cancer
37. Hepatitis C
38. Tuberculosis
39. OBSERVATION ONLY – DO NOT ASK: Surveyor, do you
observe signs or symptoms of a serious health condition?
40. Do you have a chronic health condition?
A Chronic Health Condition is defined as a diagnosed condition that is more than 3
months in duration and is either not curable or has residual effects that limit daily
living and require adaptation in function or special assistance. Examples of chronic
health conditions include, but are not limited to: heart disease (including coronary
heart disease, angina, heart attack and any other kind of heart condition or
disease); severe asthma; diabetes; arthritis-related conditions (including
arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia); adult onset cognitive
impairments (including traumatic brain injury, post-traumatic distress syndrome,
dementia, and other cognitive related conditions); severe headache/migraine;
cancer; chronic bronchitis; liver condition; stroke; or emphysema.
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes**
Client Name / HMIS ID: _____________________
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
 Data not Collected
If question #40 was answered as “Yes” (**), then the following questions are required:
40a. Do you expect this condition to be of long–continued
 No
 Client Doesn’t Know
and indefinite duration AND substantially impair your ability  Yes
 Client Refused
to live independently?
 Data not Collected
40b. Do you have documentation of the disability and
 No
severity on file?
 Yes
40c. Are you currently receiving services or treatment for
 No
 Client Doesn’t Know
this condition?
 Yes
 Client Refused
 Data not Collected
41. Do you have a physical disability?
 Client Doesn’t Know
 No
 Client Refused
 Yes**
 Data not Collected
If question #41 was answered as “Yes” (**), then the following questions are required:
41a. Do you expect this condition to be of long–continued
 Client Doesn’t Know
and indefinite duration AND substantially impair your ability  No
 Client Refused
 Yes
to live independently?
 Data not Collected
41b. Do you have documentation of the disability and
 No
severity on file?
 Yes
41c. Are you currently receiving services or treatment for
 Client Doesn’t Know
 No
this condition?
 Client Refused
 Yes
 Data not Collected
Version 1.1
Survey Part 1: Page 10 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
42. Do you have a need for a housing unit with specific features that  No
 Client Doesn’t Know
make it accessible to people with mobility or sensory disabilities?
 Yes**
 Client Refused
42a. If accommodations are necessary,
 Accessible entrance  Accessible kitchens and
which features are required?
bathrooms
 Elevator or ground
floor unit
 Rails in bathrooms
 Wheelchair accessibility
43. Have you ever had problematic drug or alcohol use, abused
 No
 Client Doesn’t Know
drugs or alcohol, or told you do?
 Yes
 Client Refused
44. Do you currently have a drug or alcohol problem?
 No
 Client Doesn’t Know
 Alcohol*  Client Refused
 Drug*
 Data not Collected
 Both*
If question #44 was answered as “Alcohol”, “Drug”, or “Both” (**), then the following questions are required:
44a. Do you expect this condition to be of long–continued
 Client Doesn’t Know
and indefinite duration AND substantially impair your ability  No
 Client Refused
 Yes
to live independently?
 Data not Collected
44b. Do you have documentation of the disability and
 No
severity on file?
 Yes
44c. Are you currently receiving services or treatment for
 Client Doesn’t Know
 No
this condition?
 Client Refused
 Yes
 Data not Collected
45. Have you consumed alcohol and/or drugs almost every day or
 No
 Client Doesn’t Know
every day for the past month?
 Yes
 Client Refused
46. Have you ever used injection drugs or shots in the last six
 No
 Client Doesn’t Know
months?
 Yes
 Client Refused
47. Have you ever been treated for drug or alcohol problems and
 No
 Client Doesn’t Know
returned to drinking or using drugs?
 Yes
 Client Refused
48. Have you used non-beverage alcohol like cough syrup,
 No
 Client Doesn’t Know
mouthwash, rubbing alcohol, cooking wine, or anything like that in
 Yes
 Client Refused
the past six months?
49. Have you blacked out because of your alcohol or drug use in the  No
 Client Doesn’t Know
past month?
 Yes
 Client Refused
OBSERVATION ONLY – DO NOT ASK:
 No
50. Surveyor, do you observe signs or symptoms or problematic
 Yes
alcohol or drug abuse?
51. Have you ever been taken to a hospital against your will for a
 No
 Client Doesn’t Know
mental health reason?
 Yes
 Client Refused
52. Have you gone to the emergency room because you weren’t
 No
 Client Doesn’t Know
feeling 100% well emotionally or because of your nerves?
 Yes
 Client Refused
53. Have you spoken with a psychiatrist, psychologist or other
mental health professional in the last six months because of your
 No
 Client Doesn’t Know
mental health – whether that was voluntary or because someone
 Yes
 Client Refused
insisted that you do so?
 No
 Client Doesn’t Know
54. Have you had a serious brain injury or head trauma?
 Yes
 Client Refused
55. Have you ever been told you have a learning disability or
 Client Doesn’t Know
 No
developmental disability?
 Client Refused
 Yes**
 Data not Collected
If question #55 was answered as “Yes” (**), then the following questions are required:
Version 1.1
Survey Part 1: Page 11 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
55a. Do you expect this to be of long–continued and
indefinite duration AND substantially impair your ability to
live independently?
55b. Do you have documentation of the disability and
severity on file?
55c. Are you currently receiving services or treatment for
this condition?
56. Do you have any problems concentrating and/or remembering
things?
57. OBSERVATION ONLY – DO NOT ASK: Surveyor, do you
detect signs or symptoms of severe, persistent mental illness or
severely compromised cognitive functioning?
58. Do you feel you currently have a mental health problem?
 No
 Yes
Client Name / HMIS ID: _____________________
 Client Doesn’t Know
 Client Refused
 Data not Collected
 No
 Yes
 No
 Yes
 No
 Yes
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 No
 Yes
 Client Doesn’t Know
 Client Refused
 Data not Collected
If question #58 was answered as “Yes” (**), then the following questions are required:
58a. Do you expect this condition to be of long–continued
 Client Doesn’t Know
and indefinite duration AND substantially impair your ability  No
 Client Refused
 Yes
to live independently?
 Data not Collected
58b. Do you have documentation of the disability and
 No
severity on file?
 Yes
58c. Are you currently receiving services or treatment for
 Client Doesn’t Know
 No
this condition?
 Client Refused
 Yes
 Data not Collected
59. Have you had any medicines prescribed to you by a doctor that
 No
 Client Doesn’t Know
you do not take, sell, had stolen, misplaced, or where the

Yes
 Client Refused
prescriptions were never filled?
60. Yes or No (no explanation necessary) – Have you experienced
any emotional, physical, psychological, sexual or other type of
 No
 Client Doesn’t Know
abuse or trauma in your life which you have not sought help for,
 Yes
 Client Refused
and/or which has caused your homelessness?
61. Have you been a victim of domestic violence or a victim of
 No
 Client Doesn’t Know
intimate partner violence?
 Yes**
 Client Refused
 Data not Collected
If question #61 was answered as “Yes” (**), then the following question is required:
61a. If you experienced domestic or intimate partner
 Within the past three months
violence, how long ago did you have this experience?
 Three to six months ago
(excluding six months exactly)
 From six to twelve months ago
(excluding one year exactly)
 More than a year ago
 Client Doesn’t Know
 Client Refused
 Data not Collected
Version 1.1
 No
 Yes**
Survey Part 1: Page 12 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
SCRIPT: Thanks so much for everything you’ve shared with me so far. Now I have some follow-up questions based on
your earlier answers.
NOTE TO SURVEYOR: Each of the following questions are applicable for certain subpopulations, only read the questions that are
applicable to your respondent.
ADULTS (18+) OR HEAD OF HOUSEHOLDS: For adults18 and older or Head of Household < 18 years old, req’d questions shaded
Question
62. Are you currently employed?
Check One Answer
 No*
 Client Doesn’t Know
 Yes**
 Client Refused
If question #62 was answered as “No” (*), then the following question is required:
62a. Are you….
 Looking for work
(read options to the right)
 Unable to work
 Not looking for work
If question #62 was answered as “Yes” (**), then the following question is required:
62b. What type of employment do
 Full-time
you have?
 Part-time
 Seasonal / sporadic (including day labor)
Comments
ADULTS (18+) w/ NO INCOME - Adults aged 18 and older having NO financial resources only (question on PAGE 3)
Question
63. If you do not have an income, and are
unable to receive general relief, what’s the
reason why?
Check One Answer
 Sanctioned
 Time Limits
 Employment
Comments
 Other
 N/A
WOMEN (15+) - Women aged 15 and older only (Age on PAGE 1)
Question
64. Are you pregnant?
Check One Answer
 No
 Client Doesn’t Know
 Yes*
 Client Refused
 N/A
If question #64 was answered as “Yes” (*), then the following question is required:
64a. What is your due date?
____/____/_______
Comments
YOUTH (17 and under) - Head of Households aged 17 and under only (Age on PAGE 1)
Question
65. Did you run away from home or a foster
care home? (Are you a runaway youth?)
Check One Answer
 No
 Yes
Comments
 Client Doesn’t Know
 Client Refused
 N/A
TRANSITION AGE YOUTH (TAY) - Head of Households aged 16 to 24 only, required questions are shaded (Age on PAGE 1)
Question
66. Are you a current or former foster care
youth?
67. Have you ever been in the juvenile justice
system?
Version 1.1
Check One Answer
 No
 Yes
 No
 Yes
Survey Part 1: Page 13 of 19
Comments
 Client Doesn’t Know
 Client Refused
 Client Doesn’t Know
 Client Refused
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
68. Have you ever been on adult probation?
69. Which of the following best represents how
you think about yourself?
 No
 Yes
 Straight
 Lesbian or Gay
 Bisexual
Client Name / HMIS ID: _____________________
 Client Doesn’t Know
 Client Refused
 Questioning
 Client Doesn’t Know
 Client Refused
VETERAN - US Veterans only, required questions are shaded (Military Service on PAGE 3)
Question
70. Which branch of the military did you serve in?
Check One Answer
Comments
 Army
 Coast Guard
 Air Force
 Client Doesn’t Know
 Navy
 Client Refused
 Marines
 Data not Collected
71. What type of discharge did you receive?
 Honorable
 General under honorable conditions
 Other than honorable conditions (OTH)
 Bad Conduct
 Dishonorable
 Uncharacterized
 Client Doesn’t Know
 Client Refused
 Data not Collected
72. When did you enter military service?
____/____/_________  Doesn’t Know
NOTE: The following questions are required for SSVF programs, but HIGHLY recommended to be completed for all veterans.
73. When did you separate from military service?
____/____/_________  Doesn’t Know
74. What is the AMI percentage for the
 Less than 30%
Household's Income?
 30% to 50%
 Greater than 50%
75. How many consecutive months were on you
on active duty status?
________ months
 Doesn’t Know
76. Do you have a service connected disability?
 No
 Client Doesn’t Know
 Yes**
 Client Refused
 Data not Collected
If question #76 was answered as “Yes” (**), then the following questions are required:
76a. What is the percentage?
________ %
 Doesn’t Know
Did you serve in any of the following wars/war eras?
77. World War II
 No
Dec. 1941 – Dec. 1946
 Yes
78. Korean War
Jun. 1950 – Jan. 1955
 No
 Yes
79. Vietnam War
Feb. 1961 – May 1975
 No
 Yes
80. Persian Gulf War (Operation Desert Storm)
Aug. 1990 – April 1991
 No
 Yes
Version 1.1
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
Survey Part 1: Page 14 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
81. Afghanistan (Operation Enduring Freedom)
Oct. 2001 - Present
 No
 Yes
82. Iraq (Operation Iraqi Freedom)
Mar. 2003 – Aug. 2010
 No
 Yes
83. Iraq (Operation New Dawn)
Sept. 2010 – Dec. 2011
 No
 Yes
84. Other Peace-keeping Operations or Military
Interventions (such as Lebanon, Panama,
Somalia, Bosnia, Kosovo)
 No
 Yes
Client Name / HMIS ID: _____________________
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
 Client Doesn’t Know
 Client Refused
 Data not Collected
SCRIPT: In order for us to assist with coordinating your care and to avoid inappropriate referrals, we'd like to ask you a few questions
about some services you may have been in contact with and a couple back-ground questions.
Department of Mental Health (DMH) and Department of Health Services (DHS) – Required questions are shaded
Question
85. What clinic(s) or program(s) have you
received mental health services at?
86. Are you enrolled in a DMH or DMH contracted
program? DMH stands for the LA County
Department of Mental Health.
*If yes, please administer DMH authorization form.
Check One Answer
______________________
 No
 Yes**
Comments
 Client Doesn’t Know
 Client Refused
NOTE: If your respondent answers “No,” but you know the
answer in #85 to be a DMH operated or contracted
program, please check “yes” and proceed to #86a.
If question #86 was answered as “Yes” (**) and/or if question #85 was answered as a DMH operated or contracted program,
then the following questions are required:
86a. When was your last visit?
 Within the past 6 months
 Client Doesn’t Know
 Longer than 6 months
 Client Refused
86b. When was the last date that you
received mental health services?
____/_____/_____
86c. To which clinic(s) have you gone?
______________
86d. Who is your primary point of contact
there?
_________________________________________
87. Have you been a patient at any of the  Do not go for care
Health Centers
following DHS hospitals or at a DHS
 Antelope Valley Health
Health Center in the past 12 months?
Center
Hospitals
DHS stands for the LA County
 Bellflower Health Center
 LAC + USC Med Center
Department of Health Services. If other,
 Dollarhide Health Center
 Harbor UCLA Med Center
please state the name of the specific DHS  Olive View Med Center
 Glendale Health Center
Health Center.
 La Puente Health Center
 Rancho Los Amigos
*check all that apply*
 Lake Los Angeles Health
Center
Multi-Service Ambulatory Care
NOTE: If the respondent lists private
Centers
 Little Rock Health Center
hospitals that are not part of the County
 Martin Luther King, Jr.
 San Fernando Health
health system, please note than in
Outpatient Center
Center
questions 26/26a
 High Desert Regional Health
 South Antelope Valley
Center
Health Center
 Wilmington Health
Continued on Next Page
Center
Version 1.1
Survey Part 1: Page 15 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Other
 Other DHS clinic
(Specify in Comment)
Comprehensive Health Centers
 El Monte Comprehensive
Health Center
 Edward R. Roybal
Comprehensive Health Center
 H. Claude Hudson
Comprehensive Health
Center
 Hubert H. Humphrey
Comprehensive Health
Center
 Long Beach Comprehensive
Health Center
 Mid-Valley Comprehensive
Health Center
If any hospital or center was answered for question #87, then the following question is required:
5
87a. How many times have you
1
6
accessed services at the DHS site(s) in
2
7
the last 12 months?
3
*If 2 or more, please administer DHS pre More than 7
4
screen form.
 Client doesn’t know
ADDITIONAL BACKGROUND QUESTIONS - All clients, required questions are shaded
Question
88. Would you be interested in housing options such as
shared housing, a room for rent, or sober living?
89. Are you required to register as a sex offender?
90. Have you ever been convicted of manufacturing or
producing methamphetamine?
Check One Answer
 No
 Client Doesn’t Know
 Yes
 Client Refused
 No
 Client Doesn’t Know
 Yes
 Client Refused
 No
 Client Doesn’t Know
 Yes
 Client Refused
Comments
PHOTO - All clients, required questions are shaded
Question
91. To finish up this section of the survey, may I take your picture so that we can
better find you if housing turns up?
If they refuse a live picture, ask if you can take a picture with them or of a photo ID.
Check One Answer
 Yes
 No
WRAP-UP INFORMATION – Required questions are shaded
Interviewer’s Information
First Name
Last Name
Email
Phone #
Org.
Version 1.1
Housing Navigator’s Information
 Same as Interviewer
 Not Yet Assigned
First Name
Last Name
Email
Phone #
Org.
Survey Part 1: Page 16 of 19
Additional Social Service or Case
Manager Contact
(Do you already work with a case manager
or outreach worker that you trust?)
First Name
Last Name
Email
Phone #
Org.
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
Client Name / HMIS ID: _____________________
Survey Information
Referring Agency (If Applicable)
 N/A
When was this survey conducted?
________ / ________ / _________ Time: ____________ AM/PM
(Date and Time)
Location of Survey (*Please update later if respondent is later attached to Housing Navigator in a different Region)
SPA
Region
City / Community
 Lancaster
 Lancaster
 SPA 1 - Antelope Valley
 Palmdale
 Palmdale
 Other
 Santa Clarita
 Castaic
 Saugus
 Valencia
 Newhall
 Val Verde
 North
 Canyon Country
 San Fernando
 Granada Hills
 Sand Canyon
 Sylmar
 SPA 2 - San Fernando Valley
 Woodland Hills
 Porter Ranch
 Winnetka
 Canoga Park
 Calabasas
 West Hills
 West
 Agoura Hills
 Westlake Village
 Chatsworth
 Hidden Hills
 Reseda
 Tarzana
 Warner Center
 Van Nuys
 Panorama City
 Lake Balboa
 Studio City
 Central
 Valley Glen
 Valley Village
 Sherman Oaks
 Northridge
 Encino
 North Hills
 North Hollywood
 Arleta
 Sunland
 Lakeview Terrace
 SPA 2 - San Fernando Valley
 East
 Tujunga
 Mission Hills
 Pacoima
 Granada Hills
 Shadow Hills
 Sun Valley
 Burbank
 Glendale
 Universal City
 Flintridge
 Glendale
 La Crescenta
 Toluca Lake
 La Canada
 Pasadena
 Monrovia
 Altadena
 Arcadia
 San Marino
 San Gabriel
 West
 South Pasadena
 Monterey Park
 Alhambra
 Duarte
 Sierra Madre
 Bradbury
 Hermon
 SPA 3 – San Gabriel Valley
 El Monte
 West Covina
 South El Monte
 La Puente
 Irwindale
 Rosemead
 Central
 Baldwin Park
 Temple City
 Azusa
 Hacienda Heights
 Covina
 Glendora
Version 1.1
Survey Part 1: Page 17 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
 East
 Downtown
 Hollywood
 North East LA
 SPA 4 – Metro/Central LA
 Silverlake/Westlake Central
 Mid-Wilshire
 SPA 5 - West LA
 West LA
 South
 SPA 6 - South LA
 North
 South East
 West
 SPA 7 - Southeast / East LA
Version 1.1
 LCA 1: Central
Client Name / HMIS ID: _____________________
 San Dimas
 Diamond Bar
 La Verne
 Walnut
 Claremont
 Industry
 Pomona
 Downtown
 Hollywood
 Hollywood Hills
  E. Ho/ Los Feliz
 West Hollywood
 Eagle Rock
 Mount Olympus
 El Sereno
 Highland Park
 Glassell Park
 Monterey Hills
 Cypress Park
 Atwater Village
 Montecito Heights
 Mount Washington
 Chinatown
 Boyle Heights
 East LA
 Silverlake
 Echo Park
 Westlake
 Pico Union
 Korea Town
 Park La Brea
 Mid-City
 Hancock Park
 West Mid-City
 Larchmont District
 Miracle Mile
 Wilshire
 Bel Air
 Santa Monica
 Beverly Hills
 Venice
 Beverly Crest
 Westchester
 Beverly Glen
 Westwood
 Brentwood
 Culver City
 Holmby Hills
 Palms
 Pacific Palisades
 Rancho Park
 Malibu
 South Robertson
 Marina Del Rey
 Laurel Canyon
 Manchester
 Mar Vista
 Compton
 Rosewood
 Florence
 Willowbrook
 South Central
 Watts
 South Los Angeles
 Crenshaw
 West Adams
 Jefferson Park
 Baldwin Hills
 University Park
 Leimert Park
 Ladera Heights
 Vermont
 West Adams
 Lynwood
 Paramount
 Hyde Park
 Windsor Hills
 Bell
 Maywood
 Bell Gardens
 South Gate
 Commerce
 Vernon
 Cudahy
 County Unincorporated
 Huntington Park
Survey Part 1: Page 18 of 19
Modified 3/19/2015
CES Survey: Part 1 (VI-SPDAT & Intake)
 La Mirada
 Montebello
 Pico Rivera
 Artesia
 Bellflower
 Cerritos
 Hawaiian Gardens
 Lakewood
 Harbor City
 Harbor Gateway
 Inglewood
 Long Beach
 Hermosa Beach
 Manhattan Beach
 LCA 2: North
 LCA 3: South
 LCA 4: Long Beach
 Harbor Area
 SPA 8 - South Bay
Client Name / HMIS ID: _____________________
 North
 Long Beach
 Beach Cities
Question
SURVEYOR ONLY – DO NOT ASK:
Is the respondent chronically homeless?
 Santa Fe Springs
 Whittier
 County Unincorporated
 Downey
 Norwalk
 County Unincorporated
 Signal Hill
 County Unincorporated
 San Pedro
 Wilmington
 Torrance
 Redondo Beach
Check One Answer
 No
 Yes
Comments
To be chronically homeless, the client must be an unaccompanied homeless individual (or
adult in a family) with a disabling condition who has been continuously homeless for a year or
more OR has had at least four (4) episodes of homelessness in the past three years. To be
considered chronically homeless, a person must have been sleeping in a place not meant for
human habitation (e.g., living on the streets) and/or in an emergency shelter during that time.
OFFICE USE ONLY:
Has the client been officially certified for any of the following?
 DHS – Housing for Health
 SSVF
 VASH
 DMH – Housing Voucher
 MHSA Certification
Is the client already receiving supportive services that can/will
follow him/her into permanent housing?
 Yes
 No
If yes, what agency provides those supportive services?
______________________________________________________
Contact Information for supportive services attachment
OFFICE USE ONLY:
ADDITIONAL SURVEYOR OSBSERVATIONS
May include observations about client or location, such as description of make-shift shelter, detailed description of vehicle (if respondent was
residing in vehicle)
I
Version 1.1
Survey Part 1: Page 19 of 19
Modified 3/19/2015
CES Survey: Part 2 (Housing Preferences)
Client Name / HMIS ID: _________________
Part 2 of the CES Survey is MUCH shorter - I’m going to ask you some questions about housing. Just to be clear, this is not a housing
application. These are just questions to get a better idea of what kind of housing might be right for you.
RESIDENCY & PREFERENCES
1. What city within the County of Los Angeles do you live in?
Agoura Hills
Downey
Alhambra
Duarte
Arcadia
El Monte
Artesia
El Segundo
Avalon
Gardena
Azusa
Glendale
Baldwin Park
Glendora
Bell
Hawaiian Gardens
Bell Gardens
Hawthorne
Bellflower
Hermosa Beach
Beverly Hills
Hidden Hills
Bradbury
Huntington Park
Burbank
Industry
Calabasas
Inglewood
Carson
Irwindale
Cerritos
La Cañada Flintridge
Claremont
La Habra Heights
Commerce
La Mirada
Compton
La Puente
Covina
La Verne
Cudahy
Lakewood
Culver City
Lancaster
Diamond Bar
Lawndale
Lomita
Long Beach
Los Angeles 
If checked, proceed to 1a
Lynwood
Malibu
Manhattan Beach
Maywood
Monrovia
Montebello
Monterey Park
Norwalk
Palmdale
Palos Verdes Estates
Paramount
Pasadena
Pico Rivera
Pomona
Rancho Palos Verdes
Redondo Beach
Rolling Hills
Rolling Hills Estates
Rosemead
1a. If you reside within the City of Los Angeles, in which community do you live in?
Atwater Village
Harbor City
Mid Wilshire
Baldwin Hills
Harbor Gateway
Miracle Mile
Bel Air
Hermon
Montecito Heights
Beverly Crest
Highland Park
Mount Washington
Beverly Glen
Hollywood
North Hollywood
Boyle Heights
Holmby Hills
Northridge
Brentwood
Hyde Park
Pacific Palisades
Canoga Park
Jefferson Park
Pacoima
Century City
Korea Town
Palms
Chatsworth
Ladera Heights
Panorama City
Chinatown
Lake Balboa
Porter Ranch
Cypress Park
Lake View Terrace
Rancho Park
Downtown Los Angeles
Larchmont District
Reseda
(Skid Row)
Laurel Canyon
San Pedro
Eagle Rock
Leimert Park
Shadow Hills
East Hollywood
Lincoln Heights
Sherman Oaks
Echo Park
Los Feliz
Silver Lake
Encino
Manchester
South Central
Granada Hills
Mar Vista
South Los Angeles
Glassel Park
Marina Del Ray
South Robertson
Hancock Park
Mid City
Southeast Los Angeles
Version 1.1
Survey Part 2: Page 1 of 5
San Dimas
San Fernando
San Gabriel
San Marino
Santa Clarita
Santa Fe Springs
Santa Monica
Sierra Madre
Signal Hill
South El Monte
South Gate
South Pasadena
Temple City
Torrance
Vernon
Walnut
West Covina
West Hollywood
Westlake Village
Whittier
Studio City
Sun Valley
Sunland
Sylmar
Tarzana
Toluca Lake
Tujunga
University Park
Van Nuys
Venice
Vermont
Warner Center
Watts
West Adams
West Hills
Westlake
Westwood
Wilmington
Wilshire
Winnetka
Woodland Hills
Modified 3/19/2015
CES Survey: Part 2 (Housing Preferences)
2. How many months have you stayed in that city/community?
(Location checked in Q1/1a)
3. What other cities have you called home within the last year (last
12 months)?
*SURVEYOR NOTE: Write the city or cities –separated by row - from
the table above in question 1
4. Is this region - where I’m surveying you right now - where you’re
looking to be housed?
*SURVEYOR NOTE: location may be different from answer to Q1/1a
4a. If no, what is the community you are looking to be housed
in?
*SURVEYOR NOTE: Please check ONLY ONE SPA.
Client Name / HMIS ID: _________________
____________ months
___________________________________
___________________________________
___________________________________
 Yes
 Yes (anywhere is fine)
 No, I have another community in mind  proceed to 4a
 SPA 1 – Antelope Valley
 SPA 2 – San Fernando Valley
 SPA 3 – San Gabriel Valley
 SPA 4 – Metro/Central LA
 SPA 5 – West LA
 SPA 6 – South LA
 SPA 7 – Southeast / East LA
 SPA 8 – South Bay
5. What community, if any, will you not accept offers for housing in?
________________________________________
QUESTIONS TO ASSIST WITH HOUSING MATCH
6. If you were able to locate housing, do you have money saved up for move-in or
housing?
7. How many adults will this unit need to accommodate including yourself?
8. Have you ever been evicted from housing or abandoned a unit, of which your name was
on the lease?
8a. If yes, approximate month and year of last eviction:
If you are unsure of the day, please select the first day of the month.
9. Were any of the evictions from Public Housing Authority units?
9a. If you’ve been evicted from a PHA unit, was it due to fraud?
9a1. If yes, approximate month and year of the last eviction due to fraud:
If you are unsure of the day, please select the first day of the month.
9b. If you’ve been evicted from a PHA unit, was it due to unit damage?
9b1. If applicable, approximate month and year of the last eviction due to
unit damage:
If you are unsure of the day, please select the first day of the month.
9c. If you’ve been evicted from a PHA unit, do you owe money?
9c1. If yes, do you have a payment plan in place?
10. Have you ever been convicted of a felony?
10a. If yes, please describe all felonies for which you have been convicted?
10b. If yes, when was the month and year of your last conviction?
If you are unsure of the day, please select the first day of the month.
10c. If you’ve been convicted, were any of the felonies considered violent?
10d. If yes, when was the month and year of your last violent felony conviction?
If you are unsure of the day, please select the first day of the month.
11. Have you ever been convicted of arson?
Version 1.1
Survey Part 2: Page 2 of 5
 Yes  No  Refused  Unsure
1
2
3
4
5
6
7
8 or more
 Yes  No  Refused  Unsure
______ / ______ / ___________
 Yes  No  Refused  Unsure
 Yes  No  Refused  Unsure
______ / ______ / ___________
 Yes  No  Refused  Unsure
______ / ______ / ___________
 Yes  No  Refused  Unsure
 Yes  No  Refused  Unsure
 Yes  No  Refused  Unsure
______ / ______ / ___________
 Yes  No  Refused  Unsure
______ / ______ / ___________
 Yes  No  Refused  Unsure
Modified 3/19/2015
CES Survey: Part 2 (Housing Preferences)
12. Have you been in jail or prison in the last 6 months?
13. Are you currently on probation or parole?
14. Do you need a smoking or non-smoking apartment?
15. Do you have a pet?
Client Name / HMIS ID: _________________
 Yes  No  Refused  Unsure
 Yes  No  Refused  Unsure
 Smoking
 Non-smoking
 No preference
 Yes  No  Refused  Unsure
15a. If yes, is it a certified service animal or emotional support animal?
16. Are there other requirements or requests around permanent housing that we need to
be aware of?
**check all that apply; read question as open ended question, and allow respondent to
respond; do not voluntarily suggest the answers listed to the right**
Version 1.1
Survey Part 2: Page 3 of 5
 Yes  No  Refused  Unsure
 1st Floor
 Elevator
 Upper Floor  Private Bathroom
 Kitchenette  Public Transit
 Other:
Modified 3/19/2015
CES Survey: Contact Sheet
Thank you for completing this survey. Your answers will help us better understand your
health and housing needs and the needs of our community, and may help us make better
referrals for you in the future.
For more information about the Coordinated Entry System or this survey, please contact:
SPA __ Community Coordinator: ____________________________________________
Phone: ________________________________________________________________
Email: _________________________________________________________________
Address of regional access center: __________________________________________
______________________________________________________________________
Follow up contact (if applicable):
Outreach Worker/Housing Navigator: ________________________________________
Phone: ________________________________________________________________
Email: _________________________________________________________________
Version 1.1
Modified 3/19/2015