CLIENT FORMS
Clients MUST be given a notification and consent form that explains HMIS and why their personal information is being collected.
An HMIS Intake Desk Sign (DOC) must also be clearly posted at all locations Client Intake is handled.
IF data is to be shared with other agencies, clients are also given a release of information form which they must sign or verbally agree to. Our Client Consent Form combines Client Consent and Release of Information into a single document.
Links to forms and instructions are in the area below.
Your agency can modify the “Client Forms” to fit your particular situation, but you are encouraged to seek legal counsel before doing so. They are designed to meet legal requirements and to provide clear information to the clients.
Agencies are responsible for arranging translation services for their clientele. One possible resource is http://www.languageline.com
Client Forms – Privacy Protection and Data Confidentiality
English
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Client Consent & ROI (PDF)
Must be signed by each client for entry into HMIS. -
Client Information Sheet (PDF)
Not to be given to client to take away. For client review at your office only. -
Client Revocation of Consent (PDF)
Must be signed to revoke consent. Special considerations apply to Data Sharing. -
Client Grievance Form (DOC)
Grievance Form
Spanish
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Forma de Concentimiento (PDF)
Must be signed by each client for entry into HMIS. -
Informacion del Cliente (PDF)
Not to be given to client to take away. For client review at your office only. -
Revocacion de Consenso (PDF)
Must be signed to revoke consent. Special considerations apply to Data Sharing. -
Client Grievance Form (DOC)
Grievance Form
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