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Kings/Tulare HMIS Intake Form

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Kings/Tulare HMIS Intake Form

Rev. 10/01/19

1. Intake Summary

Project Name

Client ID (Computer Generated)

Project Start Date

Housing Move-In Date

Intake Staff Name

2. Client Demographics

First

Middle

Last

Suffix

Name Data Quality:

Full name reported

Client Doesn’t Know

Partial, street name, or code name reported

Client Refused

Data Not Collected

SSN/Code:

Full SSN

Approx/Partial SSN

Client Doesn’t Know

Client Refused

Data Not Collected

Date of Birth/Code:

Full DOB

Approx/Partial DOB

At a minimum, approximate year of birth is required.

Ethnicity:

Non-Hispanic/Non-Latino

Hispanic/Latino

Client Doesn’t Know

Client Refused

Data Not Collected

Race:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Client Doesn’t Know

Client Refused

Data Not Collected

Gender

Male

Female

Trans Female (MTF)

Trans Male (FTM)

Gender Non-Conforming

Client Doesn’t Know

Client Refused

Data Not Collected

Disabling Condition

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Veteran Status

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Relation to Head of Household

Self (head of household)

Head of household’s child

Head of household’s spouse/partner

Head of household’s other relation member

Other: non-relation member

3. Living Situation Prior to Entry

ONLY ONE CHOICE from either A, B, or C

A. Homeless Situation: If client was homeless the night before entry, select one from here

Place not meant for habitation (vehicle, streets, parks, abandoned buildings, or anywhere outside)

Emergency shelter (including hotel/motel paid for with ES voucher)

Safe Haven

B. Institutional Situation:

Foster care home or foster care group home

Hospital or other residential non-psychiatric medical facility

Jail, prison, or juvenile detention facility

Long-term care facility or nursing home

Psychiatric hospital or other psychiatric facility

Substance abuse treatment facility/detox

C. Transitional & Permanent Housing Situation:

Host Home (non-crisis)

Hotel or motel paid without emergency shelter voucher

Owned by client, no ongoing housing subsidy

Owned by client, with ongoing housing subsidy

Permanent housing (other than RRH) for formerly homeless

Rental by client in a public housing unit

Rental by client, no ongoing housing subsidy

Rental by client, with GPD TIP subsidy

Rental by client, with HCV voucher (tenant or project based)

Rental by client, with other ongoing subsidy

Rental by client, with RRH or equivalent housing subsidy

Rental by client, with VASH housing subsidy

Residential project or halfway house with no homeless criteria

Staying in family member’s apartment/house

Staying in friend’s room/apartment/house

Transitional housing for homeless persons (including TAY)

Client Doesn’t Know

Client Refused

Data not collected

4. Length of Stay

A. Length of Stay in Prior Living Situation:

One night or less

Two to six nights

One week or more, but less than one month

One month or more, but less than 90 days

90 days or more, but less than one year

One year or longer

Client Doesn’t Know

Client Refused

Data Not Collected

B. [For Institutional Situations <90 days or TH/PH < 7 nights only]

On the night before, did you stay on the streets, ES or SH?

No

Yes

C. [For Homeless Situations, Institutional Situations <90 days or TH/PH < 7 nights only]

Approximate Date Homelessness Started

# of Times Homeless in Past 3 Years

One Time

Two Times

Three Times

Four or More Times

Client Doesn’t Know

Client Refused

Data Not Collected

# of Months Homeless in Past 3 Years

One Month (this is the first month)

2-12 Months

More Than 12 Months

Client Doesn’t Know

Client Refused

Data Not Collected

5. Program Specific Information

Covered by Health Insurance

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

If Yes, Which Source(s)

Medicaid (Medi-Cal)

Medicare

State Children’s Health Insurance Program

VA Medical Services (Military Insurance)

Employer Provided Health Insurance

Health Insurance obtained through COBRA

Private Pay Health Insurance

State Health Insurance for Adults

Indian Health Services Program

Other

Physical Disability

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Chronic Health Condition

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Mental Health Problem

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Substance Abuse

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Alcohol Abuse

Drug Abuse

Alcohol & Drug Abuse

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, expected to be of long-continued an indefinite duration and substantially impairs ability to live independently

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Developmental Disabilities

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

HIV/AIDS

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Domestic Violence Victim/Survivor

If yes, when experience occurred

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, when experience occurred

Within the past three months

Three to six months ago

Six months to one year ago

One year ago or more

Client Doesn’t Know

Client Refused

Data Not Collected

If yes, are you currently fleeing

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

Income From Any Source

If Yes, Indicate All Sources and Dollar Amounts that Apply

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

$ Earned Income

$ Unemployment Insurance

$ SSI

$ SSDI

$ VA Service-Connected Disability Compensation

$ VA Non-Service-Connected Disability Compensation

$ Private Disability Insurance

$ Worker’s Compensation

$ TANF

$ General Assistance

$ Retirement Income from Social Security

$ Pension or Retirement from a Former Job

$ Child Support

$ Alimony or Other Spousal Support

$ Other Source

Non-Cash Benefits from Any Source

If Yes, Indicate all Sources and Dollar Amounts that Apply

No

Yes

Client Doesn’t Know

Client Refused

Data Not Collected

$ Supplemental Nutritional Assistance Program (Food Stamps)

$ Special Supplementation Nutritional Program for WIC

$ TANF Child Care Services

$ TANF Transportation Services

$ Other TANF-Funded Services

$ Other Source

Client Signature

Date

Staff Signature

Date

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What the Kings/Tulare HMIS Intake Form is and who it serves

The Kings/Tulare HMIS Intake Form is a standardized client intake record used by homeless services providers in Kings and Tulare counties to capture household demographics, housing history, income and benefits, health and disability indicators, and consent for data sharing. The form supports enrollment into the regional Homeless Management Information System (HMIS) for service coordination, eligibility determination, case management, and reporting to Continuum of Care partners. It is designed for use by intake staff, case managers, outreach teams, and authorized data entry personnel and should be completed at first contact or at program enrollment.

Why accurate completion matters for clients and programs

Completing the Kings/Tulare HMIS Intake Form correctly ensures clients receive appropriate services, preserves eligibility for housing and benefits, and produces reliable program data for local Continuum of Care reporting and federal HUD requests.

Why accurate completion matters for clients and programs

Who typically completes and signs this intake form

Intake staff, case managers, outreach workers, and authorized HMIS data-entry personnel typically complete the form during initial client contact.

  • Intake staff — Collects identifying and household information at first contact and confirms consent status.
  • Case managers — Verifies income, disability status, and housing history for program eligibility and service planning.
  • Authorized data clerks — Enter final records into HMIS, run de-duplication, and ensure data quality checks.

Supervisors and program administrators review completed forms for quality assurance and reporting consistency.

Step-by-step: completing intake with minimal delays

Follow these four core steps to complete a compliant Kings/Tulare HMIS Intake Form and move the client into appropriate services.

  • 01
    Gather documents: Collect ID, proof of income, and household verification.
  • 02
    Record demographics: Enter legal name, DOB, SSN (if consented) and contact details.
  • 03
    Obtain consent: Explain data use and record signed consent choice and date.
  • 04
    Enter into HMIS: Submit completed form and run duplicate check in HMIS.

How intake flows into HMIS and case management

This sequence shows the typical flow from first contact through data entry and service assignment in the HMIS environment.

  • Client contact: Initial outreach or phone/face-to-face intake.
  • Verification: Confirm identity and eligibility documents.
  • HMIS entry: Authorized staff enter fields and save record.
  • Service linkage: Generate referrals and schedule follow-up services.

Recommended digital workflow settings for online completion

Configure your intake workflow to enforce required fields, reduce errors, and preserve privacy before submitting to HMIS.

Field Configuration
Required Field Mark name, DOB, consent, and household size as required.
Validation Use date and numeric validation for DOB and income fields.
Conditional Logic Show income fields only if client reports income.
Authentication Require staff SSO or two-factor for record submission.

Technical and platform considerations for e-submission

Ensure your platform supports secure upload, role-based access, and the file types your HMIS accepts before enabling electronic intake.

  • File formats: Accept PDF and DOCX for attachments.
  • Integrations: Salesforce, Microsoft 365, NetSuite, Box supported.
  • Authentication: SSO, MFA, and audit logging required.

Core sections included on a professional HMIS intake form

A complete intake form groups client information, household composition, housing history, needs assessment, income data, and consent details to support eligibility and service planning.

Client demographics

Collect name, preferred name, gender identity, race/ethnicity, and date of birth to support service matching and demographic reporting requirements.

Contact information

Include phone numbers, email addresses, and current mailing address; note alternate contacts and best times to reach the client for follow-up.

Housing history

Capture current living situation, length of homelessness, prior housing, and barriers to housing to determine program eligibility and placement priority.

Income and benefits

Record all income sources, benefit programs, and monthly amounts to calculate income level for funding eligibility and reporting.

Vulnerability assessment

Document chronic health issues, disabilities, veteran status, and other vulnerability indicators for prioritization and referral to specialized programs.

Consent and release

Obtain client authorization for data sharing, record the scope and date of consent, and explain how data will be used and protected.

Security and privacy checkpoints to include

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest
BAA requirement: Execute BAA when vendor handles ePHI
Access controls: Role-based permissions and least privilege
Audit logs: Retain signed activity trails and timestamps
Authentication: Enforce MFA for staff accounts
Retention policy: Document retention schedules and secure deletion

Common errors to avoid when preparing intake

  • Incomplete demographic fields such as missing DOB or partial name entries lead to duplicate HMIS records and eligibility delays.
  • Failing to document consent or using unclear consent language can limit data sharing and prevent necessary referrals.
  • Entering estimated income rather than verified amounts can produce incorrect eligibility and reporting discrepancies.
  • Not checking for existing records before creating a new entry increases duplicate-count inflation in program metrics.

Risks and potential consequences of incorrect intake data

Data breach fines: Significant regulatory penalties
HIPAA violation: Civil penalties and corrective action
Funding loss: Incorrect reporting risks program funds
Benefit denial: Clients may lose eligibility
Legal exposure: Liability from mishandled sensitive data
Audit findings: Negative audits affect credibility

Typical timing expectations for intake and data entry

Adopt these timing guidelines to keep client records current and to meet reporting and program workflow needs.

Initial intake timing:

Complete intake during first contact or within 72 hours of shelter entry.

HMIS data entry:

Enter records into HMIS within three business days of intake when possible.

Consent renewal:

Review and re-document consent annually or when scope changes.

Annual review:

Conduct comprehensive eligibility and needs review every 12 months.

Reporting cadence:

Submit client-level data per local HUD/CoC schedules (quarterly or annual as required).

Key milestones from intake to reporting

Track these sequential milestones as part of a standard service delivery lifecycle for each enrolled client.

01

Client Intake

Gather demographics, household, and consent at first contact.

02

Verification

Confirm identity, income, and disability documentation.

03

Enrollment

Complete program enrollment and assign case manager.

04

Program Reporting

Include client data in HMIS exports for CoC/HUD reporting.

eSignature vendor comparison for HMIS intake workflows

Compare basic pricing and compliance attributes among common eSignature vendors; signNow is shown first per vendor ordering rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Practical intake scenarios and outcomes

Two common scenarios show how accurate intake improves client routing and reporting for county providers.

Rapid Shelter Referral

A client completes intake at outreach

  • rapid verification confirms eligibility
  • the enrollment triggers a shelter bed referral and immediate case assignment, reducing time to shelter placement and ensuring accurate HMIS counts for the night.

Coordinated Benefits Access

Household records documented with verified income

  • case manager obtains consent for benefits release
  • the aggregated data allowed enrollment in a benefits program and improved monthly reporting accuracy to funders.

Frequently asked questions about the Kings/Tulare HMIS Intake Form

Answers to common processing, legal, and technical questions about completing or submitting the Kings/Tulare HMIS Intake Form.


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