Vet-Ride Intake Form

Central Texas Vet-Ride Intake Form
Notice of Confidentiality & Non-Disclosure

All information provided will be kept confidential and guarded against unofficial use. Information gathered through an intake or assessment may be shared to effectively plan, arrange, and deliver services to meet individual client needs.
Name*

First NameLast Name
Email
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Branch of Service (if dependent, put branch of spouse)*

ArmyNavyAir ForceMarinesSpace Force
Service Type (DD214, DD Form 2, or NGB-22 required to validate service eligibility)*

Active Duty (servicemember or dependent)Reserves (Any Branch)National GuardSpouse or Child of Veteran
Please attach Service Document here or fax to (254) 770-2349

Cancelof
Discharge Type*
Gender*

MaleFemaleDo not wish to disclose
Primary Reason for Ride Request

Medical AppointmentsBenefits (Social Security, SNAP, WIC, other)PersonalMedication Pick-Up
Disability Status

I use a wheelchairI use a cane or rollatorI have special needs for my transportation (we will call you)I am able to transfer in and out of a vehicle with no assistance
Ethnicity

Hispanic or LatinoNOT Hispanic or LatinoDo not wish to disclose
Race

WhiteAmerican Indian / Alaska NativeAsianType option 4
Marital Status

MarriedSingleDivorcedWidow
Emergency Contact Name, Relationship
Emergency Contact Telephone Number
Please enter a valid phone number.
Employment Status
Monthly Household Income (Before Taxes) for all Adults living in the home
For questions about this program, please contact our program director at george.losoya@ctcog.org , or call 800-447-7169.
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Central Texas Vet-Ride Intake Form

Notice of Confidentiality & Non-Disclosure