Forms

Forms

Select the appropriate tab below to access forms.

GENERAL

Statement of Privacy Practices – Describes how client information may be used; explains clients’ rights

HMIS Participation Posting Must be displayed by the intake desk 

CLIENT CONSENT

Consent paragraph

Using the procedures dictated in each document, add the CHIN Informed Consent paragraph to your agency’s existing intake form(s).

General Release - for use by all agencies except ones specifically noted below

CRIS – for use by CRIS agencies 

EAN for use by Emergency Assistance Network agencies (Greensboro/High-Point and others) 

VA for use by Veteran Administration agencies

Consent Form

           Stand-alone form allowing for informed consent (alternative to the consent paragraph).

INTAKE

Intake Form (ESG, HUD, CoC, HOPWA), updated as of 1/14/15,   (Self-Service Center login required)

SSVF Intake Form, updated as of 1/14/15  (Self-Service Center login required)

PATH Intake Form, updated as of 11/11/14 (Self-Service Center login required)

VI-SPDAT Intake Form (from OrgCode’s website)

List of NC Adult Care Homes (for question on project entry)

DATA SHARING

Qualified Business Sharing Agreements (QSOBAs) allow agencies to share complete client records with each other (especially useful for projects shared across agencies).  Completed forms should be sent to the Help Desk. 

Participating Agencies

Non-participating agencies

Multiple Participating agencies