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.
Are you a Veteran of the military?
If so, which branch?
Military Occupations (list all that apply)
Do you have a DD-214?
Discharge Status
Are you a member of any Veterans Association?
If so, which association?
Type of Assistance Needed (Check All That Apply)

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.
Do you have a history of substance abuse?
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)
Do you smoke cigarettes?
How many times before now have you been in a drug treatment program?
Do you have any service-connected disabilities? If yes, please list.
Have you ever been diagnosed with PTSD?
Have you ever been diagnosed with any mental health complaints or complications?
If yes, please explain.
Do you have any current mental health complaints?
If yes, please explain.
Have you ever attempted or contemplated suicide?
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)