Veteran Housing Placement Intake Form

Veteran Housing Placement Intake Form
REFERRAL SOURCE INFORMATION
Referring Organization Name:
Program Type (select one):*

HUD-VASHSSVFVA Medical / Social WorkVeteran Workforce ProgramRe-Entry ProgramOther
Case Manager / Referral Contact Name:*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Contact:*

PhoneEmailText
VETERAN APPLICANT INFORMATION
Veteran Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email, if applicable:
example@example.com
Current Housing Status:*

UnshelteredTemporarily HousedTransitionalStaying with Friends/FamilyOther
Is the Veteran Able to Live Independently?*

YesNo
Note: This housing is independent living and does not provide medical, treatment, or supervision services.
ELIGIBILITY VERIFICATION
Veteran Status Verification (select one):*

DD-214 availableVA enrollment verifiedProgram-verified veteran statusOther
Upload your DD-214 or verification letter*

Cancelof
Is this Veteran currently enrolled in or eligible for housing assistance?*

YesNoPending
If yes, specify program:
HOUSING NEEDS & PREFERENCES
Requested Move-In Timeline:*

Immediate (0–7 days)Short-Term (1–2 weeks)FlexibleFuture Placement
Preferred Placement Type:*

Shared Room (per-bed)Private Room (if available)
Maximum Monthly Housing Budget:*
$ per month
Payment Source (check all that apply):*

HUD-VASHSSVFEmployment IncomeOther AssistanceSelf-Pay
HOUSING NEEDS & PREFERENCES
Is the Veteran able to comply with house rules including: • Quiet hours • No illegal activity • Cleanliness standards • Respect for shared spaces*

YesNo
Any restrictions or considerations we should be aware of?*

SmokingPetsMobility limitationsOther
EMERGENCY & SUPPORT CONTACT (OPTIONAL)
Emergency Contact Name:*

First NameLast Name
Relationship:*
Phone Number*
Please enter a valid phone number.
PROGRAM ACKNOWLEDGMENT & DISCLAIMER*

I acknowledge that this housing is a for-profit, veteran-designated shared housing program. It is not a shelter, medical facility, or treatment program.I confirm that the information provided is accurate to the best of my knowledge and that the veteran is appropriate for independent shared housing.
Case Manager / Referrer Signature:*

Powered by Jotform SignClear
Date Signed:*

MonthDayYear
Should be Empty: