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HMIS
New Client Identifier/Profile Entry
Enter new client identifying and profile information below.  Help
 
User:  Nick Mondau
Agency:  CTED Housing Division
Program:  CTED Training Program
Access Level:  System User
Sharing Mode:   OFF / Turn On
  
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 A   A   A   A   A 
 Household Member #1 (Head of Household)
First name:
 Don't know Refused		 Middle name:
 Don't know Refused		 Last name:
 Don't know Refused		 Suffix (Jr., II, etc.):
 Don't know Refused
 Birth Month: 
 Don't know Refused		  Birth Day: 
 Don't know Refused		  Birth Year: 
 Don't know Refused		 Gender:
Male Female
Transgender Male Transgender Female
Transgender Don't know
Refused
SSN: - -
 Don't know Refused Don't have		 CTED Training Program Client Identifier: Status:
Race/Ethnicity (select one or more)
American Indian/Alaskan Native Asian
Black/African-American Hispanic/Latino
Native Hawaiian/Other-Pacific Islander White
Don't know Refused 
 Ever served on active duty in US military?
No Yes
Don't know Refused 
Immigrant or Refugee?
No Yes
Don't know Refused 
 Client's ability to understand English?
Alias/Street Name Phone Number
Case manager assigned Client Info Shared?
Yes No 
Share client's info above with what other Program's?
ALL PROGRAMS CHD Program 
  

 If you need additional entry blanks, enter the total number of household members here: 
 

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