WSVS Transitional Housing Application

Application for Transitional Housing
REFERRAL INFORMATION
Referred by
Organization
Email
example@example.com
Contact Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
VETERAN INFORMATION
Full Name*

First NameMiddle InitialLast Name
Sex:*

MaleFemaleOther
Social Security #
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Email
example@example.com
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever received services through Warrior Salute Veteran Services Outpatient in the past?*

YesNo
Have you ever received services through Warrior Salute Veteran Services Residential in the past?*

YesNo
EMERGENCY CONTACT INFORMATION
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Alternative Contact

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Marital Status*

SingleMarriedDivorcedWidowedDomestic Partner
ARMED SERVICES HISTORY
Branch*
Service Dates*
D/C Status*
Deployment History*
Narrative Reason for Separation*
MEDICAL INFORMATION
Check all that apply:*

Traumatic Brain InjuryMental Health Diagnoses (specify)Physical needs (specify)Drug Allergies (specify)Food Allergies (specify)Environmental (specify)Neurological ImpairmentEpilepsy (specify type)Other
Specify all answers from above*
Drug(s) of choice*
Last Used*
SI/HI
Suicidal Ideation
Suicide Attempt
Homicidal Ideation
Homicidal Acts
Current Medications (including dosages):*
Legal Involvement
Vocational Goals*
Treatment Goals*
What are your personal goals while in the Warrior Salute Veteran Services Program?*
Benefits (list amounts if applicable)*

SSISSDPublic AssistanceOther WagesVA PensionVA Service Connection/Disability Rating PercentageNoneOther
Amounts (if applicable)
Mobility Status (Check all that apply)*

AmbulatoryManual WheelchairAble to Negotiate StairsPower WheelchairOther
Adaptive Equipment (Check all that apply)*

Communication DeviceWheelchairComputerMobility DeviceHearing AidEye GlassesNoneOther
Transportation (Check all that apply)*

Valid Driver's LicenseSuspended LicenseHas own vehicleNo vehicle
Insurance Information*
COMMUNICATION
Primary Language*
Verbal*

YesNo
Uses Sign Language*

YesNo
Requires an Interpreter*

YesNo
HEALTH & WELLBEING
Services Currently Receiving*

Case ManagementPsychiatry/PsychologyCounselingSocial WorkOTPTSpeechNursingNoneOther
CURRENT SERVICE PROVIDERS
Primary Care Physician: *
Agency
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid fax number.
Mental Health Professional:
Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid fax number.
Specialist (Specify):
Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid fax number.
Specialist (Specify):
Agency
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Fax Number
Please enter a valid fax number.
CONSENT TO RECEIVE SERVICES/ASSESSMENT
I First Name* Last Name* understand that this application will be reviewed by the Warrior Salute Veteran Services Nucor Team and Medical Director, and that a clinical assessment may need to be completed to determine eligibility. I understand that if further clinical assessments need to be completed, the information regarding the assessment will be shared amongst the Warrior Salute Veteran Services Team.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Please include any other required documents as stated above:*

Cancelof
CONSENT FOR RELEASE OF INFORMATION
Name*

First NameLast Name
Last four of SS #:*
Initial   I hearby give permission to Warrior Salute Veteran Services to receive information from:
Person(s):
Agency:
Address:   Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number   Email
Initial   I hearby give permission to Warrior Salute Veteran Services to receive information from:
Person(s):
Agency:
Address:   Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number   Email
I nearby give permission for information to be shared in the following format:*

PhoneFaxWritinge-mailIn person
I nearby give permission for the following information to be shared:*

Intake AssessmentPRI ScreeningOrthopedic EvaluationTreatment PlanPTSD ScreeningSocial Work EvaluationPsych/Neuropsych EvaluationMedical History (including physicals, lab results and medications/allergies)Employment History/EvaluationsMental Health HistoryPPD/TB Test (1 Year)Academic PerformanceDrug & Alcohol EvaluationOT/PT/Speech ReportsOther (Please specify)
If selected "Other" above, please specify:
Information will be shared for the following purpose:
I understand that this authorization covers only the information indicated and that Warrior Salute Veteran Services will maintain the confidentiality of the information. Warrior Salute Veteran Services is prohibited from disclosure of any records it receives through use of this release. I may revoke my authorization at any time with a written request. This authorization is valid from one year from the date signed. The information obtained from the use of this release may only be used for the purpose of which it was intended. Any other use of this information is in direct violation of Confidentiality and is punishable by law.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Application for Transitional Housing

REFERRAL INFORMATION

VETERAN INFORMATION

EMERGENCY CONTACT INFORMATION

ARMED SERVICES HISTORY

MEDICAL INFORMATION

SI/HI

COMMUNICATION

HEALTH & WELLBEING

CURRENT SERVICE PROVIDERS

CONSENT TO RECEIVE SERVICES/ASSESSMENT

CONSENT FOR RELEASE OF INFORMATION