Vulnerability Index - Service Prioritization Decision Assistance Tool (VI-SPDAT) Prescreen Triage Tool Formatted for use in Seattle/King County 10-1-15. Based on VI-SPDAT 2.0 developed by OrgCode Consulting Inc. and Community Solutions, 2015

Pre-Screen Tool for Single AdultsAdministration

Interviewer’s Name

Interviewer's Phone

Staff Volunteer

Survey Date Month/Day/Year Survey Time Survey Location (be specific - include cross streets, etc.

Opening ScriptMy name is _________________, and I am a _________________ (role) with the _________________ (program). I have a 10-15 minute survey I would like to complete with you. Most questions require only a YES or NO answer. Some questions require a one-word answer. I'll be honest, some questions are personal in nature. The purpose of these questions is to help us understand your housing and service needs so we can best match you with appropriate resources. Keep in mind you can skip or refuse any question. The information is protected and stored in the Coordinated Entry component of the Safe Harbors Homeless Management Information System, a secure database that helps us connect people with housing, based on the needs and experiences you identify and the housing programs you are eligible for in King County.

All the information you tell me is confidential and you should share as much as you feel comfortable. The more information you feel comfortable sharing, the smoother the referral process will be because we will know your options and won’t waste your time referring to you programs you aren’t eligible for. I do not make assumptions and I’m required to ask each question to everyone. Please bear with me if an answer feels obvious or repetitive. If you have any questions during the assessment or want clarification, just let me know. Do you have any questions before we start?

Basic Information

First Name Nickname Last Name

In what language do you feel best able to express yourself?

Social Security Number Consent to participateDate of Birth Age

Yes No

IF THE PERSON IS 60 YEARS OF AGE OR OLDER, THEN SCORE 1. PRE-SURVEY AGE SCORE:

Interviewer’s Email

Agency

A. History of Housing and Homelessness1. Where do you sleep most frequently? (check one)

Outdoors (typical location)Other (specify):Refused

IF THE PERSON ANSWERS ANYTHING OTHER THAN “SHELTER”, “TRANSITIONAL HOUSING”, OR “SAFE HAVEN”, THEN SCORE 1. SLEEP LOCATION SCORE A1:

2. How long has it been since you lived in permanent stable housing? Refused

3. In the last three years, how many times have you been homeless? Refused

IF THE PERSON HAS EXPERIENCED 1 OR MORE CONSECUTIVE YEARS OF HOMELESSNESS, AND/OR 4+ EPISODES OF HOMELESSNESS THEN SCORE 1. CH SCORE A2:

Shelters (if known, which: _____________________________) Transitional Housing (if known, which: ________________) Safe Haven(if known, which: ____________________________)

Team

B. Risks4. In the past six months, how many times have you...

a) Received health care at an emergency department/room? Refused

b) Taken an ambulance to the hospital? Refused

c) Been hospitalized as an inpatient? Refused

d) Used a crisis service, including sexual assault crisis, mental health crisis,family/intimate violence, distress centers and suicide prevention hotlines?

Refused

e) Talked to police because you witnessed a crime, were the victim of a crime, or the al- leged perpetrator of a crime or because the police told you that you must move along?

Refused

f) Stayed one or more nights in a holding cell, jail or prison, whether that was ashort-term stay like the drunk tank, a longer stay for a more serious offence, oranything in between?

IF THE TOTAL NUMBER OF INTERACTIONS EQUALS 4 OR MORE, THEN SCORE 1 FOR EMERGENCY SERVICE USE. RISK SCORE B1:

5. Have you been attacked or beaten up since you’ve become homeless?

6. Have you threatened to or tried to harm yourself or anyone else in the last year?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF HARM.

Y N Refused

7. Do you have any legal stuff going on right now that may result in you beinglocked up, having to pay fines, or that make it more difficult to rent a placeto live?

IF “YES,” THEN SCORE 1 FOR LEGAL ISSUES. RISK SCORE B3:

8. Does anybody force or trick you to do things that you do not want to do?

Y N Refused

9. Do you ever do things that may be considered to be risky like exchange sexfor money, run drugs for someone, have unprotected sex with someone youdon’t know, share a needle, or anything like that?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR RISK OF EXPLOITATION. RISK SCORE B4:

C. Socialization & Daily Functioning10. Is there any person, past landlord, business, bookie, dealer, or government

group like the IRS that thinks you owe them money?

Do you get any money from the government, a pension, an inheritance,working under the table, a regular job, or anything like that?

IF “YES” TO QUESTION 10 OR “NO” TO QUESTION 11, THEN SCORE 1 FOR MONEY MANAGEMENT. SOCIAL SCORE C1:

Do you have planned activities, other than just surviving, that make you feel happy and fufilled?

IF “NO,” THEN SCORE 1 FOR MEANINGFUL DAILY ACTIVITY. SOCIAL SCORE C2:

11.

12.

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Y N Refused

Refused

TOTAL RISK SCORE B1+B2+B3+B4:

RISK SCORE B2:

Are you currently able to take care of basic needs like bathing, changing clothes, using a restroom, getting food and clean water and other things like that?

IF “NO,” THEN SCORE 1 FOR SELF-CARE.

Is your current homelessness in any way caused by a relationship that broke down, an unhealthy or abusive relationship, or because family or friends caused you to become evicted?

IF “YES,” THEN SCORE 1 FOR SOCIAL RELATIONSHIPS.

SOCIAL SCORE C3:

C. Socialization & Daily Functioning (continued)

13.

14.

SOCIAL SCORE C4:

D. Wellness15. Have you ever had to leave an apartment, shelter program, or other place

you were staying because of your physical health?

16. Do you have any chronic health issues with your liver, kidneys, stomach, lungs orheart?

17. If there was space available in a program that specifically assists peoplethat live with HIV or AIDS, would that be of interest to you?

Do you have any physical disabilities that would limit the type of housing youcould access, or would make it hard to live independently because you’d need help?

When you are sick or not feeling well, do you avoid getting help?

20. FOR FEMALE RESPONDENTS ONLY: Are you currently pregnant?

WELLNESS SCORE D1:

18.

19.

Has your drinking or drug use led you to be kicked out of an apartment or program where you were staying in the past?

22. Will drinking or drug use make it difficult for you to stay housed or afford yourhousing?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR SUBSTANCE USE. WELLNESS SCORE D2:

a) A mental health issue or concern?

b) A past head injury?c) A learning disability, developmental disability, or other impairment?

Do you have any mental health or brain issues that would make it hard for you to live independently because you’d need help?

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR MENTAL HEALTH. WELLNESS SCORE D3:

21.

23.

24.

IF THE RESPONDENT SCORED 1 FOR PHYSICAL HEALTH AND 1 FOR SUBSTANCE USE AND 1 FOR MENTAL HEALTH, SCORE 1 FOR TRI-MORBIDITY.

WELLNESS SCORE D4:

Y N Refused

Y N Refused

Y N Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

Y Refused

N

N

N

N

N

N

N

N

N

N

N

SOCIAL SCORE C1+C2+C3+C4:

Have you ever had trouble maintaining your housing, or been kicked out of an apartment, shelter program, or other place you were staying because of:

IF “YES” TO ANY OF THE ABOVE, THEN SCORE 1 FOR PHYSICAL HEALTH.

25. Are there any medications that a doctor said you should be takingthat, for whatever reason, you are not taking?

26. Are there any medications like painkillers that you don’t take the waythe doctor prescribed or where you sell the the medication?

WELLNESS SCORE D5:

27. YES OR NO: Has your current period of homelessness been caused by anexperience of emotional, physical, psychological, sexual, or other type ofabuse, or by any other trauma you have experienced?

IF “YES”, SCORE 1 FOR ABUSE AND TRAUMA. WELLNESS SCORE D6:

Scoring Summary by DomainSUBTOTAL

RESULTS

Score: Recommendation:

0-3: no housing intervention

4-7: an assessment for Rapid Re-Housing

8+: an assessment for Permanent Supportive Housing/Housing First

PRE-SURVEY (age 60+)

A. HISTORY OF HOUSING & HOMELESSNESSA1. Sleep Location ScoreA2. Chronic Homelessness Score

B. RISKSC. SOCIALIZATION & DAILY FUNCTIONS

D. WELLNESS

GRAND TOTAL:

Follow-Up Questions

On a regular day, where is it easiest to find you and what time of day is easiest to do so?

place:

time:

Is there a phone number and/or email where someone can safely get in touch with you or leave you a message?

phone: -

email:

IF "YES” TO ANY OF THE ABOVE, SCORE 1 FOR MEDICATIONS

Y N Refused

Y N Refused

Y Refused N

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There are just a few more questions that I'd like to ask you. Some of these questions help determine basic eligibility for different housing programs - items such as your gender, veteran status for programs that serve specific populations. May I ask you these additional questions? [Assessor - go to supplemental questions ]

Closing ScriptThank you for completing this pre-screening. I will forward this information to the Seattle/King County Veteran Housing Placement Team, and your information will be included in the list of people who need housing and services. This list is prioritized, with a goal to house people with the most severe needs and longest periods of homelessness first. The team meets weekly to review the assessments and housing options. We know from experience that it can take awhile to find housing, and you will likely hear from someone in the next three weeks to let you know which agency you have been assigned to, and where you are on the list. If you don't hear from someone, please contact met to let me know so I can follow up on your behalf. Let me check again that your contact information is correct so that when we try to find you we have the right information. [Assessor - check phone/email.]

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WELLNESS SCORE D1+D2+D3+D4+D5+D6: When using computer/fillable version, and upon finishing these questions, type "done" in box to the right to trigger wellness calculation function

King County Supplemental Questions to the VI-SPDAT for Single Adults (v. 9-1-15)

Finally I’d like to ask you some questions to help us better understand homelessness, match you with appropriate

housing and services, and improve housing and support services.

LAST KNOWN PERMANENT ADDRESS

Street Address

City State Zip

Address Data Quality:

HAVE YOU EVER SERVED IN THE US MILITARY

IF YES, Did you serve at least one day of Active Military Duty?

IF YES, Are you registered for VA Healthcare?

IF YES, What was your characterization of serivce (discharge status)

WHAT IS YOUR GENDER

ETHNICITY [All clients]

RACE More than one race is permitted. [All clients] (Client doesn’t know and Client refused should only be selected if no other response is selected. )

ARE YOU REQUIRED TO REGISTER AS A SEX OFFENDER [This question helps match people to programs that have different criteria. Answering yes does not automatically make client ineligible for housing.]

Full address reported Incomplete or estimated address reported

Refused Client doesn’t know Data not collected

Yes No Refused Client doesn’t know

Yes No Refused Client doesn’t know

Yes No Refused Client doesn’t know

Dishonorable Honorable General (Under Honorable) Other Than Honorable (OTH) Bad Conduct

Uncharacterized Client doesn’t know Client refused

Male Female

Transgender Male to Female Transgender Female to Male

Other Client refused Client doesn’t know

Non-Hispanic / Non-Latino Hispanic / Latino

Client doesn’t know Client refused

Asian White Black or African American Native Hawaiian or Other Pacific Islander

Client doesn’t know Client refused

American Indian or Alaskan Native

Yes No Refused Client doesn’t know

King County Supplemental Questions to the VI-SPDAT for Single Adults

INCOME AND SOURCES [Head of household and adult] Yes No Amount per Month

/ mo None (No Financial Resources) VA Service-Connected Disability Compensation Alimony or other spousal support Child support Earned income (i.e., employment income)

General Assistance (GA) Pension or retirement income from a former job Private disability insurance Retirement Income from Social Security Social Security Disability Income (SSDI) Supplemental Security Income (SSI) Temporary Assistance for Needy Families (TANF) Unemployment Insurance VA Non-Service-Connected Disability Compensation Worker’s Compensation Other source (specify) : Client doesn’t know Client refused

Total

HEALTH INSURANCE Select all current source(s) of health insurance coverageMedicaid (a.k.a. WA Apple Health) Medicare

Employer-Provided Health Insurance COBRA Private Health Insurance No Health Insurance

Doesn't Know Refused Not Collected

Veteran's Administration (VA) Medical ServicesQualified Health Plan (a.k.a. Obamacare)

/ mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo / mo

/ mo

VI-SPDAT Triage Notes

Note if unsheltered (Outdoors or Other). Where Staying:Outdoors Other

Shelter Plan

Review of Essential Elements and Quality Assurance

QUICK REVIEW OF ESSENTIAL ITEMSFirst Name

Last Name

Last 4SSN

Total Score

Refused

Carry Forward: Key Screening Questions and Discharge Status

times/3 yrs

Honorable General (Under Honorable) Other Than Honorable

(OTH) Bad Conduct

/60+ adds 1 point to total

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Pre-Survey Age

A1: Sleeping Place Score

A2: Chronic Homeless Score

B: Risk Score

C: Social/Functioning Score

D: Wellness Score

Screening Agency

Interviewer

Quality Assurance [Assessor - make sure you have FULLY completed / attached the following]

Signed KC Release of InformationSigned VA Release of Information (WITH agencies initialed!)

Safe Harbors Consent

KC Supplemental Questions to the VI-SPDAT

ES

TH

Save Haven

Served in the Military - YES One Day Active Duty - YES Registered with VA - YES

Registered Sex Offender - YES

Interview Date

or

Outdoors Other

NOTES FROM VOLT (to be filled out only after VOLT placement team conferencing

FINAL HOUSING NOTES:

Income Total /mo. Note if income sources are DISABILITY related (check box)

VA Svc-Connected Disability

Private Disability

SSIVA Non-Svc-Connected Disability SSDI

GA / GA-U

NOTES TO CONVEY TO VOLT / PLACEMENT TEAM

Discussed at VOLT (date) Referred to Housing/Agency: Other Follow Up / Notes: Referred to Navigator:

Contact Info: email__________________________________________________ phone: __________________________________

DishonorableUncharacterizedClient doesn’t know Client refused

Gender (not pulling forward right now - hand check)

MF

T: M->FT: F ->M

OtherRefusedDon't Know

Best Place to Find Best Time

Tri-Morbidity Score D4

The following pages contain the Release of Information for King County housing and service partners, the VA Puget Sound, plus the Safe Harbors Consent. Below is suggested language to introduce these documents so Veterans and their families understand the context for using them and safeguards in place to protect their information.

This is called a Release of Information. By signing this form,

you're giving us permission to talk with other agencies and

coordinate your entry into housing options for you. We can

then all work together to help you find housing. If we talk to

other agencies, we will only share information that is

directly related to helping to find you housing. We won't

share anything else. The purpose and intent of this form is

to connect you with housing resources. Refusal to sign the

form will limit the coordination of housing options;

however, choosing not to sign will not affect your ability to

obtain health care services or other supports that exist

outside of coordinated entry.

King County DCHS_092015

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FOR HOUSING PLACEMENT AND SUPPORT SERVICES IN KING COUNTY

Name: _______________________________________________________________________ DOB: _______________ (Please include previous or other names used)

By signing below, I give my permission to ____________________________________ to share my information to and (Name of Agency)

among the King County agencies that provide housing placement and supportive services. (a list of the participating King County agencies is available on the back of this form). I further authorize the participating King County agencies to share this information among themselves.

My information will be used to help determine eligibility for housing and related services. My information will also be used for planning and program evaluation activities.

Information to be released to and among participating agencies: Identifying information (Name, birth date, gender,

race, residential information, phone number) Financial information (employment status, income

verification, public assistance payments andallowances, food stamp allowances, etc.)

Disability Household size Program participation data that helps establish

Chronic Homeless status Agency where I have been seen for any of the

following services:o Outreach/case managemento Homeless/housing activities

Information collected in Safe Harbors For Veterans: DD-214, NGB-22 or Statement of

Military Service

VISPDAT (The results of this screening provideinformation about my health and social needs).

System Use Scores (This consists of numbers thatrepresent my use of jail, sobering, emergencydepartments, hospitals, shelter, diversion, and/ormedical respite information).

Vulnerability Assessment Score (This informationwill be shown as numbers and is available only whenI have completed a vulnerability assessment).

Other:__________________ (Initial here) _____ _______________________________________ _______________________________________ This signed authorization form

Authorization: I, _________________________________ give my permission to release information described above to assist with housing placement options. When I am asked to fill out this form, I am entitled to a signed copy of this form. I may revoke this authorization at any time except to the extent that action has already been taken to comply with it. It must be in writing and to: sent____________________________________________________________________________________.

(Print the agency name and address)

Signature ______________________________________________________________ Date _____________ (If signed by someone other than the person named at the top of the page, please print your name; provide reason, relationship & description of authority)

Please include the ways we can find you: _________________________________________________________ ( Phone number, email, friend, shelter)

Case Manager_________________________________ Phone____________ Email_____________________________ (Print name)

Without my express revocation, this authorization will expire upon the termination of the need for the records or the need for information for my participation in housing placement and program evaluation activities. I understand that the information to be released may include information regarding mental health, substance use, HIV/AIDS, and give my permission to release for the purpose of this authorization. Recipients of the above authorized information may not be required to keep the information confidential and are not subject to the same state and federal privacy rules as a health plan or healthcare provider with the exception of Alcohol and Drug Abuse providers covered by federal regulations that prohibit any further disclosure without my express authorization. I may refuse to sign this authorization form. My refusal, however, will not affect my ability to obtain health care services. If I refuse to sign, it will limit the coordination of housing placement options for me.

King County DCHS_092015

King County Agencies providing Housing Placement and Support Services

King County DCHS will review and update this list periodically and reserves the right to add or remove agencies (082015)

ARCH Interaction Transition Shalom Zone Nonprofit AssociationAbused Deaf Women Advocacy Services (ADWAS) Interfaith Task Force on Homelessness SHAREAsian Counseling and Referral Services (ACRS) Interim Community Development Association Solid GroundAttain Housing International District Housing Alliance Sound Mental HealthAuburn Youth Resources Jewish Family Services St Stephen Housing AssociationBellwether Housing Jubilee Women's Center St Vincent de PaulBread of Life Mission Kent Youth and Family Services Street Youth MinistriesCapitol Hill Housing King County Dept. of Community and Human Svcs Teen FeedCatholic Community Services (CCS) King County Dept. of Adult & Juvenile Detention The Sophia WayCatholic Housing Services Lifelong AIDS Alliance Therapeutic Health ServicesCity of Seattle, Human Services Dept. Lifewire Transitional Resources

City of Seattle, Office of Housing Low Income Housing Institute (LIHI) United Indians of all TribesCommunity House Mental Health Mary's Place United States MissionCommunity Psychiatric Clinic (CPC) Mercy Housing United Way of King County Compass Housing Alliance Multiservice Center (MSC) Urban League of SeattleCongregations for the Homeless Muslim Housing Services VA Puget Sound Healthcare SystemConsejo Counseling and Referral NAVOS Valley Cities Counseling and Consultation (VCCC)DAWN Neighborhood House Vashon Youth and Family Services (VYFS)Downtown Emergency Service Center (DESC) New Beginnings Vietnam Veterans Leadership Program (VVLP) El Centro de la Raza New Horizons Ministries Wellspring Family ServicesElizabeth Gregory Home Operation Nightwatch WA State Dept. of Veteran AffairsEvergreen Treatment Services (ETS) Peace for the Streets by Kids from the Streets WHEELExodus Housing Pioneer Human Services YMCAFirst Place School Plymouth Healing Communities Youth and Outreach ServicesFriends of Youth Plymouth Housing Group (PHG) YouthCareHarborview Mental Health Services Refugee Women's All iance YWCA Seattle Hopelink Salvation Army Other: __________________________________Hospitality House Seattle King County Public Health __________________________________Housing Authorities: King County, Seattle, Renton Seattle Mennonite Ministry __________________________________

Imagine Housing Seattle's Union Gospel Mission __________________________________

OMB Number: 290090260 Estimated burden: 2 Minutes Expiration Date: 10/31/3003

REQUEST FOR AND AUTHORIZATION TO RELEASE OF MEDICAL RECORDS OR HEALTH INFORMATION

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We expect that the time expended by all individuals completing this form will average 2 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to specifically outline the circumstances under which we may disclose data The execution of this form does not authorize the release of information other than that specifically described below. The information requested on this form is solicited under Title 38, U.S.C. The form authorizes release of information in accordance with the Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164, 5 U.S.C. 552a and 38 U.S.C 5701 and 7332 that you specify. Your disclosure of the information requested on this form is voluntary. However, if the information including Social Security Number (SSN) (the SSN will not be used to locate records for release) is not furnished completely and accurately, Department of Veterans Affairs will be unable to comply with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the authorization.

ENTER BELOW THE PATIENT'S NAME AND SOCIAL SECURITY NUMBER IF THE PATIENT DATA CARD IMPRINT IS NOT USED. TO: Department of Veterans Affairs

VA Puget Sound Health Care System 1660 S. Columbian Way, Seattle, WA 98108

PATIENT NAME (Last, First, Middle Initial)

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED. PATIENT WILL INITIAL ALL OF THE BELOW APPLICABLE TO THIS AUTHORIZATION TO RELEASE. _____Bellwether Housing ______Bread of Life Mission ______Capitol Hill Housing ______Catholic Community Services ______Catholic Housing Services _____Community Psychiatric Clinic ______Compass Housing Alliance ______Congregations for the Homeless ______DESC ______El Centro de la Raza _____Evergreen Treatment Services/REACH _____Harborview Medical Center ______Housing Authorities: King, Seattle, Renton ______Hopelink _____Imagine Housing ______ITFH _____King County Department of Community & Human Services _____LIHI _____MultiService Center _____NAVOS _____Operation Nightwatch _____Pioneer Human Services ______Plymouth Housing Group _____Safe Harbors Homeless Management Information System _____Salvation Army ______Seattle Indian Health Board ______Seattle-King County Public Health _____Seattle Human Services / Office of Housing _____SHARE/WHEEL ______Sound Mental Health _____Solid Ground ______St. Vincent de Paul _____Therapeutic Health Services _____Union Gospel Mission _____United Way King County _____Valley Cities Counseling and Consultation _____Vietnam Veterans Leadership Program_____Washington State Dept. of Veterans Affairs ______YWCA ______SELECT ALL LISTED AGENCIES VETERAN'S REQUEST: I request and authorize Department of Veterans Affairs to release the information specified below to theorganization, or individual named on this request. I understand the information to be released include information regarding the following condition(s):

DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE HUMAN IMMUNODEFICIENCY VIRUS (HIV) SICKLE CELL ANEMIA INFORMATION REQUESTED: (Check applicable box(es) and state the extent or nature of the information to be disclosed, giving the dates or approximate dates covered by each)

COPY OF HOSPITAL SUMMARY COPY OF OUTPATIENT TREATMENT NOTE(S) OTHER (Specify) VA medical, Answers from VSPDAT survey, demographic information, veteran status, income amount and source, legal information, use of case management, and VA healthcare eligibility. PURPOSE(S) OR NEED FOR WHICH THE INFORMATION IS TO BE USED BY INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED For intake purposes, housing placement and referral, case management, coordination

NOTE: ADDITIONAL ITEMS OF INFORMATION DESIRED MAY BE LISTED ON THE BACK OF THIS FORM AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this authorization, in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon receipt by the Release of Information Unit at the facility housing the records. Redisclosure of my medical records by those receiving the above authorized information may be accomplished without my further written authorization and may no longer be protected. Without my express revocation, the authorization will automatically expire: (1) upon satisfaction of the need for disclosure; (2) on year of signature (date supplied by patient: or (3) under the following condition(s): Discharge from the VA Community Housing and Outreach Services programs. NOTE: The authorization signed on this release will not exceed one year from the date signed. Date: Signature of Patient or Person Authorized to Sign for Patient

FOR VA USE ONLY IMPRINT Patient Data Card (Name, Address, Social Security Number)

Type and Extent of Material Released

Date Released Released By:

VA FORM 10-5345 SEPTEMBER 2015 THIS SUPERSEDES VA FORM 10-5345, DATED JUN.2001, WHICH WILL NOT BE USED

Department of Veterans Affairs

DRAFT

__________________________________________________________________________________________________ Witness Staff & Agency Client refused consent __________ (Agency Initial)

Safe Harbors is our community’s Homeless Management Information System (HMIS) operated by the City of Seattle for the King County continuum. The continuum appreciates your willingness to participate. Your participation will help us improve services in the community for homeless people by giving us accurate information about who is homeless and why. The King County continuum asks you to participate to collect information about you and the services you receive. We use this information to provide people experiencing homelessness with better services and measure our community's progress in providing effective homelessness support. We may also use this information to assist you with housing placement options. If you have questions about Safe Harbors or the community partners, please contact us at (206) 386-0030.

What Will Happen To My Information? Your personal information is protected by federal and state laws that ensure confidentiality of your information and is shared only with agencies who have signed confidentiality agreements. Any agency staff person who violates the signed confidentiality agreement may be subject to consequences as outlined in the Safe Harbors Agency Partner Agreement. If you suspect your information in Safe Harbors has been misused, please contact us at (206) 386-0030.

I understand: • My decision to participate in the homeless information system will not change the services I can receive from this agency.

My decision will not be used to deny me access to shelter, housing, or other assistance I may need. • I may opt out of providing personal information. If I do, I will still be asked to provide other information that won't identify

me personally. I have a right to request to view the Safe Harbors Informed Consent FAQ located on the Safe Harbors website which includes more detailed information.

• I may withdraw consent at any time by signing a “Client Revocation of Consent” form located on the Safe Harbors website.• My information will be deleted from Safe Harbors HMIS seven years after I stop receiving services.• I have the right to view the client confidentiality policies used by Safe Harbors Partner Agencies.• My information will be combined with other information from the WA State Department of Social and Health Services for

the purpose of further analysis. My name and other identifying information will not be included in any reports orpublications.

• My information may be disclosed to the funding source (Funder) to evaluate services needed, to impact public policy andunderstand the homeless and at risk population.

Important: Personal information is not entered in Safe Harbors for people who are 1) receiving services from domestic violence agencies; 2) fleeing or in danger from domestic violence, dating violence, sexual assault or stalking situation; or 3) have revealed information about being HIV positive or having AIDS. If one of these situations applies to you, DO NOT agree to have your personal identifying information collected.

I understand the above statements and consent to participate in Safe Harbors HMIS for the purposes listed in this form, and agree the information collected may be shared with partner agencies.

Dependent children under 18 in household, if any (first and last names):

_____________________________ ________________________ ___________________________

_____________________________ ________________________ ___________________________

Client Consent for Data Collection and Release of Information Form Safe Harbors Homeless Management Information System (HMIS)

________________________________________________________________________ ___________________ Client Signature (or Parent/Guardian) Date ________________________________________________________________________ ___________________ Client Name - Printed Date of Birth Safe Harbors HMIS For Agency Use Only: Client Consent for Data Collection and Release of Information

Version 2.1 – 7/21/15

_______________________________________________________________________________________Witness Staff & Agency Client refused consent __________ (Agency Initial)