HCH Information Resource Center

This webpage contains tools from Health Care for the Homeless (HCH) grantees to aid other HCH grantees and providers. Please note that publication of these tools does not imply any endorsement by the National HCH Council.

Administrative Guidelines

Advisory board guidelines
Admission procedure for community living services
Agency information sheet
Appeals process- negative admission decisions for community living services
Applicant admissions packet list/instructions for community living services
Child abuse reporting requirements/acknowledge policy
Child protection manual
Client legal/human rights and grievance procedures
Cold night shelter training booklet
Consumer rights & responsibilities
Cooperative quality improvement program
General admissions criteria for community living services
Guidelines for determining homeless eligibility
Homeless screening, certification, and re-certification
Notice of confidentiality
Patient grievances
Policy/procedure for ambulatory care
Sample safety guidelines
Sexual conduct policy/agreement

Assessment Tools – General Medical

Addiction TB screening / assessment form
Adult physical examination
Adult physical examination
CIWA-A/narcotic withdrawal scale
Clinical assessment
Clinical assessment for alcohol and drug client- Client Form B
Clinical assessment supplemental data
Clinical staffing notes
Diagnosis testing follow-up form
Family planning history/physical exam
Fever- child
Fungal infection of foot
Gynecology exam
Head Lice
Health history and physical exam
Health maintenance assessment form- 1 month through adolescent
Immunization record
Mammogram questionnaire
Non-productive cough
Nursing assessment form
Pediatric developmental milestones
Pediatric screen
Poison Oak
Viral “flu” syndrome
Women’s health form

Assessment Tools – Mental Health and Substance Abuse

Addiction assessment form
Addiction discharge summary
Addiction recovery verification of attendance form
Addiction severity index
Addiction severity index
Addiction treatment behavioral contract
Addiction treatment check list
Addiction treatment plan- Diagnosis and formulation of problems
CAGE addiction assessment
CIWA-A/narcotic withdrawal
Clinical assessment for alcohol and drug client- Client Form B
Mental health questionnaire
Mini mental state examination
Protocol for evaluating alcohol/other drug-using battered women
Psychiatric evaluation
Psychiatric follow-up visit
Psychiatric status
Psychiatric/social needs assessment
Psychological evaluation
Psychosocial assessment
Psychosocial case management assessment
Psychosocial report
Zung depression scale

Assessment Tools – Social Service

Adult social service interview
Assessment/evaluation for services
Co-service coordination strengths assessment
Social service risk assessment form
Social work staffing notes

Chart Review

Alcohol/substance abuse
Behavioral risk assessment
Breast/cervical cancer screening
Case management
Domestic violence screening/worksheet
Family planning
Geriatric risk assessment
Immunization screening
Medication reaction
Pediatric growth and development
Sexually transmitted disease screen
TB screening

Client Application/ Registration

Application for participation
Applicant information summary
Client change form
Client information change form
Client registration form
Documented lack of income
Eligibility verification for homeless assistance programs
Patient registration form
Patient registration form
Registration form

Client Logs – Documenting Progress of Patients

Adult health promotion matrix
Adult progress notes- Episodic visit
Antiretroviral therapy flow sheet
Case management tracking sheet
Case management progress notes
Chronic problem list
Diabetes health promotion matrix
Diabetes maintenance form
Health maintenance sheet
HIV flow sheet
HIV specific flow sheet
Issue list
Medication administration record- One time orders
Outreach progress notes
Patient parameters
Pediatric progress notes- Episodic visit
Pregnancy referral flow sheet
Preventative care data form
Preventive care profile
Progress notes
Social work progress notes
TB preventive therapy flow sheet
Vaccine administration record

Clinical Guidelines

Adult screening, counseling, immunization guidelines
Athlete’s Foot
Cold symptoms
Triage guidelines
Triage guidelines

Consent Forms

Admission/discharge/follow-up agreement policy
Authorization for exchange of information
Authorization for release of treatment and/or medical information
Behavior contract
Child abuse reporting requirements/acknowledge policy
Child care program agreement
Client consent to treatment
Client permission to release information
Confidentiality of alcohol and drug abuse clients
Confidentiality of client records- Drug abuse services
Consent for Depo-Provera
Consent for follow-up evaluation/release info.
Consent for HIV viral load analysis
Consent for release of medical information
Consent for release of information
Consent for release of information
Consent for treatment
Influenza vaccine information/consent form
Informed consent and agreement to HIV testing
Permission to release HIV viral load analysis
Release authorization for immunization record
Request for medical records from another facility
Sexual conduct policy/agreement
Statement of client declination of advice or plan of care
Translation services consent
Treatment plan review/agreement

Encounter/ Billing Forms

Adolescent encounter
Baseline information form
Bill coding form
Bill coding form
Bill coding form
Client encounter report
Client visit data collection
Encounter form
Encounter form
Encounter form
Encounter record
Encounter record
Encounter record
Financial assessment/sliding fee assignment
Immunization encounter report
Intake/encounter form
Medical team encounter record
Mental health/substance abuse encounter form
Mental health team encounter record
Outreach encounter record
Pediatric encounter form
Pediatric encounter form
Social work daily encounter form
Telephone record

Health History

Adult health history
Adult screening history
Comprehensive pediatric history
Drug history
Family planning history/physical exam
Health assessment/history
Health history
Health history for dental referrals
Health questionnaire
Historia Medica- Adult health history in Spanish
History and physical form
History and physical exam
Medical/dental history
Medical history
Patient history
Patient history
Pediatric history

Intake Forms

Adult problem list
Brief intake for case management services
Case management intake
Intake form
Intake form
Intake form
Intake form
Intake form
Intake form
Intake form
Intake/encounter form
Initial demographic
Initial screening
Initial/updated assessment form
Intake evaluation
Patient eligibility form
Prenatal admission form
School/day care
Social service intake

Referral/Request for Services

Authorization for restorative services of community residences
Case management referral
Client referral
Client referral
Clinical family services referral
Convalescent care admission/referral
Dental referral
In-team referral
Interagency referral
Interagency referral
Interagency referral- prenatal care
Nutrition referral
Outreach referral
Pediatric medical clearance for ambulatory/same day surgery program
Pregnancy referral flow sheet
Referral form
Referral information
Request birth certificate/ID card
Request for change of formula
Request for immunization
Request for services
Social work referral

Staff Logs – Documenting Provider Encounters

Blood glucose monitoring system- Daily quality control record
Daily encounter report
Encounter form
Laboratory processing log
Medication inventory tracking sheet
Social service log
TB screening/referrals- Quality improvement program
Walk-in client list

Treatment Plans

Addiction treatment plan- Diagnosis and formulation of problems
Aftercare plan
Case coordination
Client case management plan
Interdisciplinary care plan
Ninety-day treatment plan – 1st & Follow-up
Drug abuse day care services- Treatment plan update
Drug abuse day care services- 90-day treatment plan
Treatment plan review/agreement
Youth treatment plan

Dental Forms

Dental clinic client survey
Dental problems
Dental professional volunteer application
Dental program office survey
Dental record
Dental record
Dental referral
Medical/dental history
Health history for dental referrals
Plan of treatment / Plan de tratamiento (English/Spanish)- Dental

Miscellaneous Forms

Advisory board application
Advisory board questionnaire
Consumer advisory board- regulations/application
Discharge summary
Employment/support status form
Family/social relationships assessment form
Multicultural HIV prevention- Competency assessment for organizations
Multicultural HIV prevention- Competency assessment for service providers
Multicultural HIV prevention competency assessment- Facilitator guide
Interdisciplinary assessment form
Legal status assessment form
Multidisciplinary problem list
Pediatric appointment reminder- English/Spanish
Pediatric lifecycle tracking chart
Pocket card- For urgent medical needs
Physician/nurse volunteer application
Quality assurance plan