VA Pre-Qualification Referral Form
Home Instead partners with the Veterans Affairs Administration to help you maximize the home care benefits you have earned!
Client's Name:
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Date of Birth:
-
Month
-
Day
Year
Date
Client's Social Security Number:
Client's VA Affiliation - Choose One:
Veteran
Surviving Spouse
OPTIONAL: Has the Client recently been seen by a VA-affiliated primary care physician or VA hospital?
Yes
No
If so, please include the name of the physician or VA hospital below:
1. Was the Veteran honorably discharged?
Yes
No
2. Did the Veteran serve at least 90 consecutive days of active duty, with at least one day during any of the following wartime periods?
World War II [12/7/1941-12/31/1946]
Korean War [6/27/1950-1/31/1955]
Republic of Vietnam [11/1/1955-8/4/1964]
Vietnam [8/5/1964-5/7/1975]
Gulf War [8/2/1990-TBD]
3. If surviving spouse, were you married to the veteran at the time of death?
n/a
Yes
No
4. Is there a need for assistance with ADLs or IADLs (including Bathing, Dressing, Transportation, Incontinence, Housekeeping, Laundry, Cooking, Shopping, Medication Reminders, Ambulation, or Custodial Care)?
Yes
No
What email address would you like VA referral information sent to?
example@example.com
Miscellaneous Information:
Submit
Should be Empty: