Veteran Housing Placement Intake Form

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

Other
Case Manager / Referral Contact Name:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Preferred Method of Contact:
VETERAN APPLICANT INFORMATION
Veteran Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email, if applicable:
example@example.com
Current Housing Status:

Other
Is the Veteran Able to Live Independently?
Note: This housing is independent living and does not provide medical, treatment, or supervision services.
ELIGIBILITY VERIFICATION
Veteran Status Verification (select one):

Other
Upload your DD-214 or verification letter

Cancelof
Is this Veteran currently enrolled in or eligible for housing assistance?
If yes, specify program:
HOUSING NEEDS & PREFERENCES
Requested Move-In Timeline:
Preferred Placement Type:
Maximum Monthly Housing Budget:
$ per month
Payment Source (check all that apply):
HOUSING NEEDS & PREFERENCES
Is the Veteran able to comply with house rules including: • Quiet hours • No illegal activity • Cleanliness standards • Respect for shared spaces
Any restrictions or considerations we should be aware of?

Other
EMERGENCY & SUPPORT CONTACT (OPTIONAL)
Emergency Contact Name:

First NameLast Name
Relationship:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PROGRAM ACKNOWLEDGMENT & DISCLAIMER
Case Manager / Referrer Signature:
Date Signed:

MonthDayYear
Should be Empty: