Name including alias, Address, Borough, Family Composition (if application is for a family), SSN, DOB, Gender, Income/Entitlements, Education, Marital Status, Ethnicity, Primary Language, Citizenship, Important Contacts
Verification that the HIPAA Compliant Authorization is signed by applicant and the agency has a record of the original form
Current Housing Location
Housing/Homeless history including dates; Housing type, Facility name, Street address. If applicant was homeless on the streets or non-municipal shelters, documentation must be attached to the application providing more specific information including dates of homelessness and description of homelessness (places stayed, the more specific the better)
Clinical Disorders and Other Conditions that may be a focus of Clinical attention as defined by the DSM-IV-TR or DSM-5
Assisted Outpatient Treatment (AOT) or Assertive Community Treatment (ACT) status
Activities of Daily Living
Checking any ADLs the applicant may require assistance with due to a medical or mental health conditions previously indicated. Provide explanation for any items checked. List includes: Feeding and Meal Preparation; Housekeeping; Managing Finances; Personal Hygiene; Traveling: Hearing; Sight; Cognitive Functions
List names of psychotropic and non-psychotropic medication in appropriate category. Indicate level of support applicant will need to maintain medication compliance once they are housed
Current Treatment/Service Providers
List of applicant’s current treatment and service providers, including, but not limited to, medical, mental health and case management services providers/programs, Health Home
Managed Long Term Care (MLTC) / Insurance provider
If applicant was a victim of DV, information about the services received and how long ago the domestic violence occurred
Age of first psychiatric hospitalization; # of psychiatric hospitalizations in the past 3 years; Name of hospital, dates of admission/discharge and service (psychiatric or medical)
Health and service providers in need of more information on the HRA PACT system can contact the PACT technical user support at 929-221-4515 or email firstname.lastname@example.org.
For assistance completing the 2010e, contact CUCS (www.cucs.org) at (212) 801-3300.