Veterans Programs Assistance Application

Veterans Programs Assistance Application

Apply for assistance at Cerebrum Rehabilitation Center. Please complete all sections accurately. Sensitive data such as SSN is not collected.
Applicant Information

Please provide your personal details.
Full Name*

First NameLast Name
Date*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Military Service Information

Please provide your military background.
YesNo
If so, which branch?
Military Occupations (list all that apply)
YesNo
Discharge Status
YesNo
If so, which association?
Drug/Alcohol/Lifestyle Rehabilitation: InpatientDrug/Alcohol/Lifestyle Rehabilitation: OutpatientCivil CommitmentCriminal CommitmentMilitary Veterans Restorative Justice Programs: Civil LitigationMilitary Veterans Restorative Justice Programs: Criminal Justice - Pre-TrialMilitary Veterans Restorative Justice Programs: Criminal Justice - Post-TrialMilitary Veterans Restorative Justice Programs: ProbationMilitary Veterans Restorative Justice Programs: ParoleMilitary Veterans Restorative Justice Programs: IncarceratedVeterans Disability CompensationHomelessness/TransportationVeterans Organization Assistance (e.g., American Legion, VVA)Other
If you selected 'Civil Litigation', please explain
If you selected 'Criminal Justice', please complete the following as applicable.
Charge (conviction)
Length of Sentence
Length of Incarceration
Survey

Please answer the following questions about your health and background.
Are you currently on prescribed medication? If so, please list.
YesNo
Drug of Choice
Last Drug Use (approximate date)

MonthDayYear
Date
How severe is your substance use problem? (1=Low, 10=Severe)

1

2

3

4

5

6

7

8

9

10

1 is 1 (Low), 10 is 10 (Severe)
How strong is your desire to change your life? (1=Low, 10=Strong)

1

2

3

4

5

6

7

8

9

10

1 is 1 (Low), 10 is 10 (Strong)
YesNo
How many times before now have you been in a drug treatment program?
Do you have any service-connected disabilities? If yes, please list.
YesNo
YesNo
If yes, please explain.
YesNo
If yes, please explain.
YesNo
If yes, please explain.
Emergency Contact Information

Please provide contact information for your emergency contact.
Full Name*

First NameLast Name
Relationship to Applicant*
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Personal Contact Information

Personal contacts are not allowed to receive certain information, per federal and state law.
Full Name

First NameLast Name
Relationship to Applicant
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Submitted By (Applicant or Other)

If completed by someone other than the veteran, please provide your information.
Full Name*

First NameLast Name
Relationship to Applicant
Should be Empty:

Veterans Programs Assistance Application

Applicant Information

Military Service Information

If you selected 'Criminal Justice', please complete the following as applicable.

Survey

Emergency Contact Information

Personal Contact Information

Submitted By (Applicant or Other)