Veteran Housing Pre-Screening Intake Questionnaire
Full Legal Name
*
First Name
Last Name
Preferred Name (optional)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
City & State
*
Best way to contact you
*
Phone
Email
Text Message
Are you a U.S. Veteran?
*
Yes
No
Branch of Service
*
Army
Navy
Marines
Air Force
Coast Guard
National Guard
Are you currently connected to the VA?
*
Yes
No
Unsure
Current housing status
*
Homeless (unsheltered)
Emergency shelter
Transitional housing
Temporarily staying with others
Other
How soon do you need housing?
*
Immediately
30 days
60–90 days
Have you lived in shared housing before?
*
Yes
No
Can you manage your own medications (if applicable)?
*
Yes
No
Can you prepare your own meals?
*
Yes
No
Can you manage personal hygiene independently?
*
Yes
No
Can you manage transportation on your own?
*
Yes
No
Can you live in a shared home with house rules?
*
Yes
No
I understand this is independent living housing only and not a medical, mental health, or care facility
*
I understand
I understand I am responsible for my own medical care, meals, transportation, and daily needs
*
I understand
How did you hear about us?
*
VA / HUD-VASH
SSVF Provider
Continuum of Care
Case Manager
Social Media
Word of Mouth
I consent to being contacted regarding housing availability and assessment
*
I consent
Anything else you’d like us to know? (optional)
Submit
Should be Empty: