VA Pre-Qualification Referral Form
Home Instead of Mecklenburg County partners with the Veterans Affairs Administration to help you maximize the home care benefits you have earned!
Client's Name
*
First Name
Last Name
Main Contact 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? Type a question
*
World War II [12/7/1941 - 12/31/1946]
Korean War II [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, Incontinence Care, Housekeeping, Laundry, Cooking, Shopping, Medication Reminders, Ambulation, or Custodial Care)?
*
Yes
No
What email address would you like the VA referral information sent to?
example@example.com
Miscellaneous Information:
Submit
Should be Empty: