Run Coordinated Entry Assessment and Prioritization Form — Free

Assessment Context

Assessment Date (required)

Date this assessment is being completed.

Access Point / Organization Name (required)

Assessor Name (required)

Assessor Role / Title (required)

Assessment Location Type (required)

If 'Other', describe the assessment location

HMIS Client ID (if existing record)

Leave blank if this is a new HMIS enrollment. Do not enter Social Security Number here.

Informed consent for data collection and HMIS entry has been obtained from the household (required)

Per HUD HMIS Data Standards and applicable privacy law, informed consent must be documented before collecting PII. Check only after consent is confirmed.

Yes No N/A

Household Composition

Household Type (required)

Head of Household Age (years) (required)

Age of the primary adult or youth head of household.

Total Number of Household Members (including head of household) (required)

Number of Minor Children (under 18) in Household

Does the head of household identify as a U.S. Military Veteran? (required)

Veterans may be eligible for HUD-VASH or GPD programs. This does not affect general CoC prioritization.

Head of Household Gender Identity

Optional. Used for program matching and equity reporting per HUD 2024 HMIS Data Standards.

Head of Household Race / Ethnicity

Optional. Select all that apply. Used for HUD equity reporting only.

Housing History and Homelessness Duration

Current Living Situation at Time of Assessment (required)

Select the option that best describes where the household slept last night (HUD HMIS Element 3.917).

Months Continuously Homeless in Current Episode (required)

Number of consecutive months the household has been homeless without a break of 7+ consecutive nights in permanent housing. Required for chronic homelessness determination (24 CFR 578.3).

Number of Separate Homeless Occasions in the Past 3 Years (required)

Count each distinct episode separated by 7+ nights in permanent housing. A total of 4+ occasions totaling 12+ months may qualify as chronically homeless.

Total Months Homeless Across All Episodes in the Past 3 Years (required)

Preliminary Chronic Homelessness Status (required)

Based on the above history and disability documentation (see next section), indicate the preliminary determination. Final determination requires verification per 24 CFR 578.3.

Date Last in Permanent Housing

Approximate date the household last resided in permanent housing. Leave blank if unknown.

Primary Reason for Current Homelessness Episode (required)

If 'Other', describe the primary reason

Disability and Health Documentation

Does the head of household have a documented qualifying disability? (required)

A qualifying disability is one that is expected to be long-continuing or indefinite in duration and substantially impairs the ability to live independently (24 CFR 578.3).

Type(s) of Qualifying Disability (select all that apply)

Required for PSH eligibility determination. Select all that apply.

Disability Verification Source

How is the disability being documented? Required for PSH enrollment.

Is the household currently engaged in mental health treatment or services?

Is the household currently engaged in substance use treatment or recovery services?

Are there any medical conditions that significantly affect the household's ability to maintain housing or access services?

Briefly describe how the medical condition(s) affect housing stability (do not record diagnosis names here)

Describe functional impacts only (e.g., 'requires ground-floor unit', 'needs proximity to dialysis center'). Do not record specific diagnoses in this field.

Vulnerability and Risk Indicators

Number of times the household used emergency services (ER, ambulance, crisis line) in the past 12 months (required)

Has the household had any overnight hospitalizations in the past 12 months? (required)

Has any adult household member been incarcerated in the past 12 months? (required)

Does the household have current safety concerns (e.g., active threats, DV, trafficking, hate crimes)? (required)

Describe the nature of safety concerns (general terms only; do not record perpetrator names)

Use general terms (e.g., 'fleeing intimate partner violence', 'active threat from former associate'). Do not record names of alleged perpetrators.

Has the household engaged in survival sex or experienced sexual exploitation in the past 12 months?

Optional. This information is used to connect households with specialized trauma-informed services. Declining does not affect prioritization.

Does the household present with tri-morbidity (co-occurring mental health, substance use, and chronic medical condition)? (required)

Tri-morbidity is a high-acuity indicator associated with highest vulnerability scores in VI-SPDAT and similar tools.

Total Vulnerability Score (from standardized tool, if used)

Enter the total score from your CoC's approved vulnerability assessment tool (e.g., VI-SPDAT, SPDAT, or locally validated instrument). Leave blank if not applicable.

Assessment Tool Used to Generate Score

Housing Preferences and Barriers

Housing Program Types the Household is Interested In (select all that apply) (required)

Geographic Area Preference or Requirement

Note any geographic requirements (e.g., proximity to school, medical provider, support network).

Accessibility or Accommodation Needs (ADA / Fair Housing Act)

Select all that apply. These are used to match the household to accessible units and request reasonable accommodations per the Fair Housing Act and ADA.

Known Barriers to Housing Placement (select all that apply) (required)

Identifying barriers enables targeted case planning and resource connection.

Current Income Sources (select all that apply) (required)

Estimated Total Monthly Household Income (required)

Used for program income eligibility screening. Exact income figures are collected during program enrollment.

Prioritization Recommendation and Next Steps

Recommended Housing Intervention (required)

Select the most appropriate housing intervention based on vulnerability, chronic homelessness status, and available inventory.

Priority Level for Housing Waitlist (required)

Assign priority level per your CoC's written prioritization policies (required under HUD Notice CPD-17-01).

Is immediate safety action required before housing placement? (required)

Flag if the household requires immediate safety planning, crisis intervention, or emergency shelter placement before standard housing process.

Describe the immediate action taken or required (required)

Referrals Made at Time of Assessment (select all that apply)

Scheduled Follow-Up Date

Date the assessor or case manager will follow up with the household.

Assessor Notes (additional context relevant to prioritization)

Include any context not captured above that is relevant to housing prioritization or service matching. Do not include diagnoses, SSNs, or other unnecessary PII.

Assessor Signature (required)

By signing, the assessor certifies that the information recorded is accurate to the best of their knowledge and was collected with the household's informed consent.

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Run: Coordinated Entry Assessment and Prioritization Form