Enhanced Care Management (ECM) Comprehensive Assessment - Section E

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* 1. Today's Date

Today's Date

Date

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* 2. First Name

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* 3. Last Name

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* 4. Date of Birth

Date of Birth

Date

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* 5. Email

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* 6. SMS Text

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* 7. Where do you live? (check all that apply)

House

Apartment complex

Board and care facility

Residential treatment center

Assisted living

Nursing home

Permanent supported housing

Protective housing

Homeless

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* 8. If you are homeless, where are you staying?

I am NOT homeless

Transitional housing

In a motel

In a shelter

With friends

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* 9. Are you worried about losing your housing?

Yes, and here is why:

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* 10. Is anyone currently helping you with your housing support (for example, housing navigator, case management, or tenants’ rights)?

Yes

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* 11. The place where I'm staying right now has the following:

Good lighting

Good heating

Good cooling

Rails for any stairs/ramps

Hot water

Indoor toilet

A door to the outside that locks

Stairs to get into your home or stairs inside your home

Elevator

Space to use a wheelchair

Clear ways to exit your home

I have additional concerns about living safely and easily around the place I stay which are:

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* 12. Do you feel physically and emotionally safe where you currently live?

Yes

No, and here's why:

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* 13. Is anyone staying in your home without your permission?

Yes, and here's who:

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* 14. Are you afraid of anyone or is anyone hurting you?

Yes, and here's why:

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* 15. Is anyone using your money without your OK?

Yes, and here's who:

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* 16. In the last 12 months, did you or other adults in your household ever cut the size of your meals or skip meals because there was not enough money for food?

Yes

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* 17. How often are you hungry or do not eat because there is not enough food in the house?

Often

Not often

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* 18. Do you eat less than you feel you should because there is not enough food?

Yes