Clone of Veteran Intake Form

Veteran Intake Form

Complete this intake form to request housing, support services, and placement review. Please answer all applicable questions accurately and provide any additional details that may help with assessment and coordination.
Veteran Information
Date of Intake*

MonthDayYear
Date
Referral Source
Intake Completed By
Desired Move-In Date

MonthDayYear
Date
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Name
Government ID Number
Gender
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address
Marital Status
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Military and VA Information
ArmyNavyAir ForceMarinesCoast GuardOther
Service Dates*
HonorableGeneralOther Than HonorableMedicalUnknown
YesNo
VA ID Number
VA Case Manager Name
VA Case Manager Phone
Please enter a valid phone number.Format: (000) 000-0000.
VA Case Manager Email
example@example.com
Authorization Number
Housing Need and Support Needs
Transitional HousingLong-Term Supportive HousingRecovery HousingHospice Partnership PlacementRespite StayOther
Housing Need - Other
Describe current situation / need*
Meal SupportLaundry AssistanceTransportation CoordinationMedication RemindersMobility AssistanceOther
Functional Support Needs - Other
Primary Diagnoses
Allergies
Medication List
IndependentCaneWalkerWheelchairNeeds Assistance
LowModerateHigh
YesNo
If yes, hospice provider
Behavioral / Safety Concerns to be aware of
Substance Use and Recovery
AlcoholOpioidsCocaine / CrackMethamphetamineMarijuanaOther
YesNo
YesNo
Substance Use - Other
No current use reportedActive useEarly recovery (0–90 days)Recovery (90+ days)Medication-assisted treatment (MAT)Other
Date of Last Use

MonthDayYear
Date
NoOutpatient counselingInpatient / Residential treatmentAA / NA / Peer supportMAT clinicOther
Currently enrolled in treatment/support - Other
Current recovery supports
NoYes
If yes, explain
Triggers / relapse risks / supports we should know
YesNoUnsure
Legal, Supervision, and Reentry
NoProbationParoleVeterans CourtBond / PretrialOther
Supervision - Other
Case worker / probation officer name
Case worker / probation officer Phone / Email
NoYesPrefer not to disclose
None reportedViolence historyArson historyTheft / property offensesSubstance-related offensesOther
History affecting housing - Other
NoYesUnknown
NoYes
EmploymentID documentsBenefitsCounselingTransportationOther
Reentry goals - Other
YesNo
Roommate compatibility concerns
Financial, Room, Transportation, Goals, and Documents
Private PayVA FundingSSI / SSDIPensionAgency PlacementOther
Income / Payment Source - Other
Monthly Income
Semi-Private RoomPrivate RoomPremium SuiteNo Preference
Medical AppointmentsPharmacyGroceryVA AppointmentsSocial / RecreationOther
Transportation Needs - Other
Stable HousingRecovery SupportIncrease IndependenceEnd-of-Life ComfortEmployment ReadinessOther
Personal Goals - Other
ID / Driver LicenseVA CardSS CardInsurance CardMedication ListOther
Documents Requested - Other
ApprovedPending ReviewWaitlistDeclined
Move-In Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Notes
Signatures
Veteran / Representative Signature*
Veteran / Representative Signature Date*

MonthDayYear
Date
Should be Empty:

Veteran Intake Form

Veteran Information

Military and VA Information

Housing Need and Support Needs

Substance Use and Recovery

Legal, Supervision, and Reentry

Financial, Room, Transportation, Goals, and Documents

Signatures