JCF Intake Form

Please remember HIPAA when sharing case information and remove names and other PII so as to keep the case as generic as possible.*
Veteran Address with City & County:
Veteran Phone and/or Email:
example@example.com
Veteran Date of Birth:

MonthDayYear
Date
Does this Veteran have any dependents? If so how many and what ages are they?
What is the Veteran’s status?

HonorableOther than HonorableDishonorableCurrently Serving
What branch of service is/was the Veteran in? What component?

Active DutyNational GuardReservesArmyAirNavyMarineCoast Guard
Is the individual seeking assistance a family member of the Veteran?

YesNo
If yes, is the Veteran deceased?

YesNo
What were the Veterans dates of service? Start Date:

MonthDayYear
Date
End Date:

MonthDayYear
Date
Did the Veteran deploy? If so how many times? Please include dates and location of the deployment.
Has the Veteran applied for benefits from the VA?

YesNo
If yes, which benefits is the Veteran receiving?
If no, why has the Veteran not filed with the VA?
What community resources has the Veteran utilized, if any?
Do I have permission to share this situation with fellow community resources?

YesNo
What is the deadline for services needed?
Case Manager Name:
Case Manager Phone/Email:
example@example.com
What is the immediate need? Please let us know of anything else you can think of that would help us in assisting this Veteran.
Should be Empty: