Veteran Directed Care Program
Apply today for the Veteran Directed Care program!
Date of Application Completion
*
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Month
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Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Email:
example@example.com
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code:
*
Best way to contact you?
Email
Phone
Morning
Afternoon
Please check all daily living assistance activities you would like help with:
Bathing
Dressing
Eating
Grooming
Transferring
Toileting
Transportation using your vehicle
Transportation using caregiver's vehicle
Household cleaning
Yardwork
Laundry
Meal prep
Shopping
To qualify, you must meet intermediate level of care. Please select all that apply to you:
Assistance with the completion of at least 2 ADLs; OR
Assistance with at least 1 ADL and assistance with medication self-administration; OR
At least 1 skilled nursing service or skilled rehabilitation service; OR
24-hour support in order to prevent harm due to cognitive impairment, as diagnosed by a physician or other licensed health professional acting within his or her applicable scope of practice, as defined by law
Are you currently enrolled in VA Healthcare?”
Yes
No
How did you hear about the Veteran Directed Care Program?
Submit
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