To help me create Haitian Creole versions of the intake form

Check this box if you are completing this application for someone other than yourself. If yes, what is your name and relationship to the consumer? ______________________________________________________________

First Name Last NameMiddle Name or Initial Preferred Name

Phone 1 Title (ex. Cell, Home, etc.) Phone 1 Instructions (ex. Call after 5pm) Phone Number 1 Phone 1 can receive

text/SMS

Phone 2 Title (ex. Cell, Home, etc.) Phone 2 Instructions (ex. Call after 5pm) Phone Number 2 Phone 2 can receive

text/SMS

Physical Street Address City Zip Code CountyApt #

Mailing Address is the same as the Physical Address

Mailing Street Address Apt # City Zip Code County

Demographics (Page 1)

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations. This intake remains valid for three (3) years from the date of completion, unless the

consumer attains adulthood (age 18) within that period. Please note that certain programs may require updated documentation on an annual basis.

Coalition for Independent Living Options

1

“Promoting Independence for People with Disabilities.”

Start Date: ___________________________ Primary Staff: _________________________

Service Provider or Representative

Family Member of Person with Disability

Contact Type: Person with DisabilityNo Type

E-mail Secondary E-mail

Yes NoAre you head of the household? How many people live in the household?

Preferred Method of Contact: E-Mail Text Phone Other: _________________________________

I give permission to receive newsletters and updates via email.

I would like to be excluded from receiving newsletters and email updates.

Yes No Who is your health insurance provider? (Blue Cross, Sunshine, Humana, etc)

Do you have health insurance?

Demographics (Page 2)

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

2

“Promoting Independence for People with Disabilities.”

Date of Birth Age

Social Security Number

Veteran Status

Veteran (Served in Military) Non-Veteran (Never served in Military)

ILP Status ILP Target Date WaivedSigned

Gender FemaleMale Do Not Wish To Disclose

Pronouns

Ethnicity Non-HispanicHispanic or Latino Do Not Wish To Disclose

Primary Language Secondary Language

American Indian/Alaska Native Asian

Black or African American

Native Hawaiian or Other

Pacific Islander

White

Multi-Racial

Haitian

Guatemalan Cuban

Jamaican

Unknown/Declined to Respond

Hispanic/Latino

Race(s) (Select all that apply) Marital Status

Divorced

Single

Married

Widowed

Unknown

Housing Status

Assisted Living

Dependent - Family/Friends

Homeless

Independent

Institution

Other

Employment Status

Full-Time

Part-Time

Unemployed

Supported

Retired

Other Education Level

Below 8 Gradeth

9 - 11 Gradeth th

High School Diploma

Trade or Vocational School

Special Education

Some College

Bachelor’s Degree

Master’s Degree

Some Graduate

Doctorate Degree

Other

Preferred Method of Contact

Phone Texting Email TTY or Video Relay Services Large Print

Braille

Registered Voter?

Yes No N/A

Annual Household Income?

$_________________ a year. How did you hear about us?

Alimony or Other Spousal Support Child Support Earned Income From Job Financial Support From Family Members Medicaid/Medicare Other Source of Income Pension

Source of Income

Private Disability Insurance SSI/SSDI Supplemental Nutrition Assistance Program (SNAP) Temporary Assistance for Needy Families (TANF) Unemployment Insurance Veteran's Disability Payment

Primary Disability

How does your disability impact your day to day life?

Secondary Disability

I agree to participate in the Coalition for Independent Living's Multimedia Marketing Efforts, which may include appearances or cooperation in various media, including video, television, newspapers, newsletters, magazines, brochures, websites, and social media.

I decline to participate in the Coalition for Independent Living's Multi-Media Marketing.

Multi-Media Release

Institutional Risk Status

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

3

“Promoting Independence for People with Disabilities.”

Relocated to Community-Based Living A consumer who successfully relocates from a nursing home or other institution to a community-based living arrangement (including apartments, private housing, self-directed assisted living, or self-directed with family or friends).

Continued in Community-Based Living A consumer who was considered eligible for nursing home or institutional placement (based on State criteria) who received IL services that prevented the necessity of entering a nursing home or institution.

At Risk for Institutionalization Relocated Continued

Additional Questions

Emergency Contact Relationship

Yes Are you in a domestic violence situation?

No Yes Do you have an emergency preparedness plan?

No

Yes

Do you receive SSI/SSDI benefits?

No I would like more information on how to apply or have questions.

Yes

Have you been the victim of a crime within two years?

No I would like a referral to the Victims of Crime Advocacy department.

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

CILO Policies

CILO Records PolicyA. __________ The rules that govern Centers for Independent Living’s confidentiality/records policies state that any representative of CIL’s funding sources, auditors, and/or accrediting bodies may review consumer files for bona fide reasons.

B. __________ Client Assistance Program Disability Rights Florida implements the Client Assistance Program on behalf of the State of Florida. If you have any problems or questions that the Coalition for Independent Living Options, Inc. cannot help you with, you may contact the CAP Program for advice and assistance. Please write this information down for future reference.

Disability Rights Florida 2473 Care Drive, Suite 200 Tallahassee, Florida 32308

1-800-342-0823 (Voice) 1-800-346-4127 (TDD)

C. File Access/Release/Confidentiality Policy _________ All consumer files are stored within a secure digital database, safeguarded by password protection and multiple layers of security features. Center staff will have access to my file and I have the right to review my file at any time.

_________ Volunteers and interns will have access to my file only if they have successfully passed a level 2 background check and have signed a written statement of ethics/confidentiality as applies to CILO services.

_________ I and/or my significant other (with signed authorization) have the right to review the record and to schedule an appointment with the Chief Programming Officer if I have concerns.

_________ I acknowledge that third-party records generated by individuals outside CILO personnel will not be photocopied or disclosed unless mandated by a court order or with my signed authorization. In certain cases of domestic violence or sexual assault, records may be considered privileged and, therefore, may not be released even when there is a court order. In these rare instances, legal advice will be sought.

_________ I must provide signed authorization in order for information about me or my family to be mutually exchanged between CILO and other parties, such as service/healthcare providers. I will always reserve the right to revoke the agreement by notifying CILO.

_________ CILO is in the process of digitizing records, transitioning away from hard copies. Files closed for more than five (5) years will be permanently removed from our system.

Signature: ______________________________________________

Witness: ________________________________________________

Date: ____________________

Date: ____________________

4

CILO ensures service delivery for every individual with a disability who voluntarily contacts the agency expressing a need for assistance, so long as that service falls within the agency’s

mission and scope of practice.

Coalition for Independent Living Options

_________ I understand the CILO services are only provided during such time that CILO has the funding to provide such services. The funding sources, staff, and programming may be subject to change at any time.

Please read the following statements and initial beside them to indicate your understanding.

1.

_________ I understand that CILO is a social service agency, and its employees are considered mandatory reports. As such, the staff is mandated by state and federal statutes to report suicidal disclosures, homicidal disclosures, disclosures of child abuse, incompetent person abuse, vulnerable adult abuse, and elder abuse, and to report the willful infection of another with a contagious condition known to be fatal.

2.

CILO reserves the right to terminate services to any consumer under the following conditions:

_________ If staff feels threatened or bullied.1.

_________ If there is a suspicion of drug, alcohol, or prescription drug abuse.

_________ If the consumer demonstrates an excessive lack of follow-through/follow-up with service referrals or service recommendations. (Examples include, but are not limited to, a consumer who does not return calls, attend meetings, or demonstrate an active interest in working on the goals drafted in the Independent Living Plan.)

_________ If staff is sexually harassed, defined as unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature.

_________ If a consumer demonstrates discrimination of any kind against any other person. (Examples include, but are not limited to, negative comments or jokes and discriminatory treatment toward a CILO staff member, consumer, volunteer, visitor, Board member, or other community partner.)

2.

3.

4.

5.

_________ I understand that in the event that services are terminated for any of the reasons stated above, I have a right to appeal this decision to the CPO within 10 days of notification of the termination of services. Grievance policy and procedure are listed on our website at www.cilo.org.

6.

Signature: ______________________________________________

Witness: ________________________________________________

Date: ____________________

Date: ____________________

5

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

National Voter Registration Act

Staff Only (Only complete if client selects yes to the questions above.)

6

Client Name: ______________________________________________

Staff Name: ______________________________________________

Date: ____________________

Date: ___________________

Yes No

If you are not registered to vote where you live now, would you like to apply to register to vote today?

If you are registered to vote where you live now, would like to update your voter registration record?

Yes No

1. 2.

Address Change

Client Applied For: How Client Applied: Client:

New Services/Assistance

Renewal of Services/Assistance

At Home

By Phone

In Person

Online

Submitted Registration Application

Did not Complete the Question

Mailed Form On __________ (Enter Date)

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

Consumer’s Authorization to Request & Release Information

7

I authorize CILO to release and request information from the following agencies and/or individuals below to enable agencies/individuals to collaborate to facilitate the services I requested.

I, _____________________________________, hereby give my consent to allow the Coalition for Independent Living Options, Inc. (CILO) to release and/or request information as specified below to/from the following individuals and/or agencies. This authority is given voluntarily, and it expires three years from the date of this document.

Landlord: Department of Children and Families (DCF)

Employer:

Attorney:

Family Member:

Family/Neighbor:

School:

Moving Company:

Other:

Legal Aid Society

Social Security Administration

Agency of Persons with Disabilites

Florida Rural Legal Services

Florida Power and Light (FPL)

Area Agency on Aging

Vocational Rehabilitation

_______________________________

This authorization is limited to the specific information pertaining to myself and/or my child or family member named above. Examples of allowable exchange of information include but are not limited to school records, medical records, financial records, reports, etc.)

_______________________________

_______________________________

_________________________

________________________

_________________________________

________________________

_________________________________

____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Consumer Printed Name: _______________________________________________________________

Consumer Signature: ___________________________________________________________________

Signature of Witness: ___________________________________________________________________

Witness Printed Name: _________________________________________________________________

Date Signed: _______________________

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

CSR GOALS & Independent Living Plan

8

Goal: ________________________________________________________________________________________

Consumer:

Program (Funding Source):

Staff:

Office:

Area of Access:

Goal Type:

Topic Area:

Begun: _________________________________

Accomplished:___________________________

Cancel: _________________________________

Target Date: ____________________________

Review Date: ___________________________

Revised Date: ___________________________

Continue Date: __________________________

Report Complete: ________________________

Report Due: _____________________________

Core Service: ILST Advocacy Peer Support I&R Transition

Staff Tasks Consumer Tasks 1._______________________________________

2._______________________________________

3._______________________________________

4._______________________________________

5._______________________________________

6._______________________________________

1._______________________________________

2._______________________________________

3._______________________________________

4._______________________________________

5._______________________________________

6._______________________________________

Outcome/Results: _____________________________________________________________________________

Consumer Signature:

Staff Signature: Date:

Date:

Consumers can refuse the right to an Independent Living Plan by signing below: Consumer Signature: __________________________________________________ Date: _________________

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

Consumer Needs Assessment

9

Independent Living Services Information & Referral Services

CILO provides consumer-based services: services and programs that are based on needs identified by our consumers. To help us provide the services that are most valuable to you, please complete this form

by checking the box of the services you need and return it to staff via email, fax, or US Mail.

How to Take Care of Myself Learn How to Do Chores Meeting Other People/ Healthy relationships Understanding Money and Budgeting Independent Living Skills Classes Roommate Matching Home Modifications/Accessibility Adaptive Medical Equipment Benefits Assistance Food Stamps (SNAP) Medicaid, Medicaid Waiver, Medicare Premium Assistance, Medicare Assistance Getting Medical Care Getting Mental Health Care Getting Vision Care or Eyeglasses Getting Dental Care Transportation Training Hurricane and Emergency Preparedness Sign Language or other Communication Assistance/Classes Financial Assistance for Rent or Utilities Food Pantry & Skills Training Paper Goods and Toiletries Hygiene Products Smoke Detectors for Home Veteran Services Durable Medical Equipment Assistance

Meals Program Housing Homeless Issues Caregiver Services Transportation Options

Transition From Nursing Home into Independent Living Maintaining Independent Living Youth Transition from Teen to Adult (See Youth Transition Services Section)

Advocacy Services

How to Advocate or Stand Up for Myself Educational Advocacy & Accommodations Social Security Benefit Programs Help with Voter Registration and Voting

Peer Support & Mentoring

Support Groups Social Groups Recreation and Leisure Activities Coping Skills, Counseling, or Therapy

Transition Services

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

Consumer Needs Assessment (Page 2)

10

Laws & Regulation Needs Youth Transition Services

CILO provides consumer-based services: services and programs that are based on needs identified by our consumers. To help us provide the services that are most valuable to you, please complete this form

by checking the box of the services you need and return it to staff via email, fax, or US Mail.

Disability Discrimination Voting Rights Civil Legal Assistance Landlord/Tenant Issues Family Law Issues Immigration Legal Assistance Personal Injury Attorney Crime Victim Services Domestic Violence Assistance Fair Housing Assistance CILO Presentation Special Education Guardianship Assistance Understanding Benefits/Expedited Enrollment Elder Law Assistance Able Trust Assistance Special Needs Trust Assistance Employment Discrimination Assistance Getting Accommodations for a Disability Building Accessibility/Accommodation Disability-Specific Training Disability Sensitivity Training (For Employers)

IEP/504 Development and/or Advocacy Transitioning From Teen to Adult Job and Social Skills Development Volunteer Work/Experience Help Applying for College or Scholarships Youth Leadership Forum

Employment Related Needs

Job Search Assistance Resume Writing Interviewing Skills How to Dress for an Interview or Access to Interview Clothing Job Readiness Skills Computer Classes Learning New or Different Job Skills After Acquiring a Disability ADA Compliance/Reasonable Accommodations

Printed Name: ________________________________

Signature: ____________________________________

Thank you for allowing us to be part of your road to independence!

Date: _______________________

Relationship: _________________

Other Needs: _______________________________________________________________________________________ _______________________________________________________________________________________

Full Name Yes Are you a U.S. Citizen?

No

Full Name Date of

Birth Age Race/Ethnicity

Social Security Number

Gender Pregnant (Yes/No)

Due Date

Relationship to Head of Household

Veteran (Yes/No)

FAA HMIS Additional Information

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

1

“Promoting Independence for People with Disabilities.”

Section 1: Household Information

Are you pregnant? Due Date (if applicable)

Section 1A: Household Members

Section 2: Crisis & Safety

Is your crisis related to COVID-19? Yes No

When did this crisis start? _____________________

Please explain your situation in your own words (Declaration of Crisis):

What is the main reason for your crisis? (check all that apply)

☐ Bereavement expenses (funeral, loss of loved one) ☐ Income reduced ☐ Lost job ☐ Medical expenses ☐ Personal/family expenses ☐ School expenses ☐ Seasonal/migrant work ended

☐ Money stolen/theft ☐ Weather-related expenses ☐ Income delayed ☐ Rent increase (30% or more) ☐ Flood displacement ☐ Other: __________________________

FAA HMIS Additional Information

If you need assistance with completing this application or require it in an alternate format, please let us know. We are happy to provide reasonable accommodations.

Coalition for Independent Living Options

2

“Promoting Independence for People with Disabilities.”

Section 3: Housing & Living Situation

What was your prior living situation? (check one) Homeless Situation ☐ Place not meant for habitation ☐ Emergency shelter, including hotel or motel paid for with emergency voucher, house shelter ☐ Safe Haven Institutional Situation ☐ Foster care home or foster care group home ☐ Hospital or other residential non-pychiatric medical facility ☐ Jail, prison, or juvenille dentention facility ☐ Long-term care facility or nursing home ☐ Psychiatric hospital or other psychiatric facility ☐ Substance abuse treatment facility or detox center

Temporary Housing Situations ☐ Transitional housing for homeless persons (including homeless youth) ☐ Residential project or halfway house with no homeless criteria ☐ Host home (non-crisis) ☐ Staying or living in a friend’s room, apartment or house ☐Staying or living in a family member’s room, apartment or house Permanent Housing Situation ☐ Rental by client, no ongoing housing subsidy ☐ Rental by client, with ongoing housing subsidy ☐ Owned by client, with ongoing housing subsidy ☐ Owned by client, no ongoing housing subsidy Other ☐ Client doesn’t know ☐ Client prefers not to answer

What was your most recent start date of homelessness? _______________________

How long did you stay in your last living situation? ☐ One night or less ☐ 2–6 nights ☐ 1 week–1 month ☐ 1–3 months ☐ 3–12 months ☐ 1 year or longer

How many times have you been homeless in the past 3 years (living on the street, in a shelter, or in a place not meant for living)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 or more ☐ I don’t know

Total number of months homeless in the past 3 years: ☐ 1 ☐2 ☐3 ☐4 ☐5 ☐6 ☐7 ☐8 ☐9 ☐10 ☐11 ☐12 ☐More than 12 months ☐ I don’t know ☐ Prefer not to answer ☐ Data not collected

Homelessness means the time you are living on the street, in a place not meant for living (like a car, tent, or abandoned building), or in a shelter.

Your “start date” is the first day you were without stable housing. If you stay temporarily with a friend or family member (like sleeping on a couch for a few nights), your homelessness starts over when you return to the street or a shelter.

Example: If you were evicted on October 1st and stayed on the street until October 15th, but then a friend let you sleep on their couch for two nights, your homelessness “start date” would reset after those two nights when you returned to the street.

Palm Beach County Continuum of Care

Informed Consent and Release of Information Form

Informed Consent and Release of Information - Rev. 07/2025 1/1

Family Member’s Names:

1.

2.

3.

4.

5.

6.

7.

8.

Signature: Date:

I understand that partners with other Palm Beach County agencies to help

meet my service needs. These agencies are members of a confidential network named the Client Management

Information System (CMIS). By providing this consent, individuals authorize the sharing of confidential information

with Palm Beach County’s Community Services Department (CSD) through its internal systems, including the Online

System for Community Access to Resources and Social Services (OSCARSS) and the Resource and Referral Portal

 CMIS is a database which allows homeless service agencies to capture and share information about the

individuals they serve

 Palm Beach County’s Community Services Department (CSD) OSCARSS system enables clients who are

experiencing homelessness or at risk of homelessness to apply for housing assistance.

 Palm Beach County’s Resource and Referral Portal system allows agencies within our network to refer

clients to additional homeless, health, and behavioral health service providers.

 This information will help you access the appropriate resources to better meet your needs. It will also save you

time should you access services from another member agency

 Only authorized staff in the CMIS, OSCARSS, and Resource and Referral Portal system can access your record

 All information entered into the CMIS database is stored using secure technology which protects data from

unauthorized users

 Non identifying information is used to provide reports for various funding agencies

 Any Information entered into the CMIS database will be maintained for an indefinite timeframe

 You have the right to request a copy of your file in all systems

 You have the right to refuse to answer any or all questions you consider sensitive

 You have right to cancel this release of information for any future data input, however certain financial

assistance programs may have statutory mandated information requirements

I have received an oral explanation of this form and hereby grant permission for and authorize the release and sharing of any

information regarding myself/children entered into this database to member agencies.

Client and/or Legal Guardian

Printed Name:

Consumer Name:

Complete and submit BUDGET REVIEW every 30 days

Date Review was completed:

Disposable income at the time of review = END OF THE MONTH BALANCE: Total Income -Total Expenses (this will auto populate)

INITIAL 0

1ST MONTH - 30 days after intial review

0

2ND MONTH - 60 days after initial review 0

3RD MONTH - 90 days after initial review 0

RENT

FOOD EARNED INCOME ($ FROM A JOB)

NON FOOD (TOILET PAPER, TOOTHPASTE, SOAP, MOUTHWASH,

PAPER GOODS, ETC.)

UNEARNED INCOME

ELECTRIC UNEMPLOYMENT BENEFITS

WATER SOCIAL SECURITY BENEFITS (SSI, SSDI, SSA) or other Disability

GAS TANF (Temporary Assistance to Needy Families)

GARBAGE FOOD STAMPS

PHONE FOOD PANTRY- multiply the # of pounds of food received by $1.68

CABLE DINE-multiply the # deliveries received by $55.00

CAR PAYMENT MEDICARE PREMIUM ASSISTANCE - multiply the number of beneficiaries in the household by $145.00

INSURANCE TOTAL

GAS/OIL TRANSPORTATION TOBACCO

HAIR CUTS TOTAL INCOME 0.00

HAIR SUPPLIES TOTAL EXPENSES 0.00

LAUNDRY BALANCE 0.00

DAYCARE MEDICAL (private, OR self pay )

RECREATION

AMOUNT SAVED

CLOTHING AMOUNT SHORT

OTHER(Savings)

OTHER

TOTAL This will auto populate

END OF THE MONTH BALANCE

SURPLUS/DEFICIT

BUDGET

OUTCOME DETERMINATION for FIND Consumers ONLY At 90-day review answer the following question:

Has consumer increased AND maintained increased dispoosable income for 90 days or more?

(Circle one) YES or NO

MONTHLY EXPENSES

MONTHLY INCOME

02/03/2020