Veterans Connect Intake Form
Your information is kept confidential and only shared with your permission.
Personal Data
Full Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
MM/DD/YYYY
Best Phone Number
*
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this a temporary address or shelter?
Email Address
example@example.com
Gender
Male, Female, or leave blank
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Branch of Military Service
*
Army, Marine Corp, Navy, Air Force, National Guard, Reserve, Coast Guard, etc.
Date of Enlistment
*
Date of Discharge
*
Rank at Discharge
*
Character of Service
*
Honorable
General
Other than Honorable
Bad Conduct
Dishonorable
Do you have a Disability Rating?
*
Please Select
Yes
No
If yes, what percentage?
Combat Veteran Status
Please Select
Yes
No
Employment Details
Employment Status
*
Working
Self-employed
Retired
Unemployed
Disabled
Other
If unemployed, are there any unique circumstances you feel contribute to your unemployment? (Health issues, mental problems, criminal background, etc.)
Would you like to be contacted if there are job events?
Yes
No
List of Agencies who are helping your family (like Name of Church, Charities, Officials). Please provide a contact person and number if you have it.
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Household Information
Residence status
*
Own
Rent
Living with family
Living with friends
Unhoused
Do you have a child under 18 or who is an adult in your care?
*
Please Select
Yes
No
Are you currently in an abusive relationship or unsafe household?
Do you have a support system (family, friends, advocates)?
Feel free to share as much detail as you feel comfortable with- or answer yes or no.
Do you have an adult or senior in your family that needs care?
*
Please Select
Yes
No
How many people live with you? (Include yourself.)
*
How many people travel and sleep where you do?
Are you currently unhoused or at risk of homelessness?
*
Please Select
Yes
No
I'm past due
I have an eviction notice
If you have an eviction notice, have been/ being forced to move out, when is your deadline? What are the circumstances?
Share as much detail as you feel comfortable with.
Do you currently live in a place with:
Pest Infestation
Open Sores or Injuries
Unfit living situations
Other
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Have you ever been evicted before? If yes, list the dates and reason(s):
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Financial Data
What monthly bills are you currently paying?
Electricity
Water
House Rent
Card loan
Insurance
Phone
Internet
Car note
Other
What are your income sources or money for daily needs?
*
Employment income
Pension
Social Security Service
Loans
No income
VA Benefits
SSI/SSDI
Unemployment
How much is your monthly income?
*
If you are currently employed or self employed, what is your current occupation?
If you aren't currently working, when was your last job?
Do you have health insurance?
*
Please Select
Yes
No
It's ending soon
Not sure
Who provides your insurance?
*
Own
Employer
Government
Do you have life insurance?
*
Please Select
Yes
No
Not sure
Have you faced financial crisis due to any of the following? (Check all that apply)
Job Loss
Medical Bills
Divorce
Loss of a Loved One
Natural Disaster
Domestic Violence
Mental Illness
Substance Use
Other
Let's further clarify your needs.
Tell us more about the type of support you're seeking...
Do you need help in regards to your daily transportation? If yes, then please specify below and provide the reason why.
Are you having issues related to housing? Is the housing not affordable? If yes, let us know the circumstances.
Comments/Suggestions/Feedback:
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Mental Health & Medical Conditions
Feel free to decline answering. These questions aim to identify resources to support you during this challenging time.
Have you been diagnosed with any mental health conditions? If yes, please check all that apply.
PTSD
Depression
Anxiety
Bipolar Disorder
Substance Abuse
Schizophrenia
Suicidal Thoughts
Have you ever been hospitalized for a mental or physical health issue? If yes, please explain.
Are you currently receiving mental health services?
Please Select
Yes
No
I'm seeking services
Do you take medication for any mental or physical conditions?
Please Select
Yes
No
If yes, please list medications.
Do you have any chronic health conditions? If yes, please specify.
Incarceration/ Justice Involvement History
Have you ever been incarcerated? If yes, provide dates and reasons.
Are you currently on parole or probation?
Please Select
Yes
No
Have you faced legal issues due to substance use or abuse?
Please Select
Yes
No
Do you need assistance with legal services?
Please Select
Yes
No
Adverse Event & Financial Crisis
What major life event led to your current housing or financial situation? (Check all that apply.)
Loss of Employment
Illness
Divorce
Death of a Family Member
Natural Disaster
Domestic Violence
Military Related Service Injury
Other
Have you applied for financial assistance programs before? If so, indicate what programs.
What is your immediate need for housing or services?
Not applicable
Emergency shelter
Permanent housing
Medical Services
Employment
Mental Health Services
Substance Abuse Treatment
Legal Assistance
Someone to listen
Long-Term Housing Needs Assessment
What type of housing assistance are you looking for?
Permanent Supportive Housing
Temporary Housing
Assisted Living
Rental Assistance
Not Applicable
Other
How many bedrooms do you need?
1
2
3
4+
What is your preferred location for housing?
City of Richmond
Henrico
Chesterfield
Other
Do you have any pets or service animals? If so, list type and number of animals.
Demographics & Special Considerations
Do you identify as a part of any minority group?
Please Select
Yes
No
If yes, specify.
Are you a part of the LGBTQ+ community?
Please Select
Yes
No
I prefer not to answer
Have you experienced any form of discrimination? (race, gender, sexual orientation)
Please Select
Yes
No
I'm not sure
Do you feel safe in your current living situation?
Please Select
Yes
No
Sometimes
Are you or have you been in an abusive household/ relationship?
Please Select
Yes
No
If yes, would you like to be connected to domestic violence resources?
Please Select
Yes
No
Do you require special assistance due to medical or mental health conditions?
Please Select
Yes
No
Is there anything that you want to share with us that we may not have discussed during this intake process?
Submit
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