Veteran Intake Form
Standard intake form for veterans seeking transitional housing or services. Please complete all applicable fields and provide documentation as requested.
Personal & Contact Information
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Gender Identity
Male
Female
Transgender
Other
Gender Identity - Other
Government Identification Number
Are you a Veteran?
*
Yes
No
Email Address
example@example.com
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Military Service Information
Branch of Military
*
Date of Service
*
Type of Discharge
*
Service-Connected Disabilities
VA Benefits Status
*
Enrolled
Not Enrolled
Housing Status & Employment History
Are you seeking transitional housing placement?
*
Yes
No
Do you have any housing restrictions?
*
Yes
No
Housing Restrictions - Explanation
Highest Level of Education Completed
*
Less than High School
High School Diploma
Some College
Associate’s
Bachelor’s
Other
Highest Level of Education - Other
Total time worked during lifetime
Type of Employment / Skills or Experience
Medical History & Current Care
Do you have any chronic medical conditions?
*
Yes
No
Chronic Medical Conditions - Details
Are you currently taking any prescribed medications?
*
Yes
No
Medications and Dosages
Primary Care Provider
Date of Last Physical Exam
-
Month
-
Day
Year
Date
Have you ever been diagnosed with a mental health condition?
*
Yes
No
Mental Health Condition - Details
Are you currently receiving mental health treatment or counseling?
*
Yes
No
Current Mental Health Treatment - Where
Have you ever struggled with substance use or addiction?
*
Yes
No
Substance Use / Addiction History and Current Recovery Status
Are you currently enrolled in or seeking substance abuse treatment?
*
Yes
No
Immediate Needs & Goals
Immediate Needs After Release
*
Housing
Mental Health Services
Medical Care
Identification / Documents
Transportation
Other
Immediate Needs - Other
Short-term Goals
Do you require assistance with daily living activities?
*
Yes
No
Do you use any mobility aids?
*
Yes
No
Do you have any dietary restrictions or special nutritional needs?
*
Yes
No
Dietary Restrictions / Special Nutritional Needs - Details
Behavioral Screening & Program Acknowledgements
Have you experienced behavioral outbursts or aggression?
*
Yes
No
Are you willing to follow house rules and program guidelines?
*
Yes
No
Substance Abuse History (behavioral screening)
Are you currently using illegal substances or alcohol?
*
Yes
No
Have you participated in behavioral or anger management programs?
Yes
No
Resident understands smoking rules (OUTSIDE ONLY)
*
Yes
No
Do you understand this is a shared living environment?
*
Yes
No
Do you understand and agree to maintain environmental and personal responsibility?
*
Yes
No
Do you understand that this is a 30-day intake and observation period?
*
Yes
No
Do you understand that this is a drug and alcohol-free environment?
*
Yes
No
Do you understand that you MUST give a 30-day notice to move out?
*
Yes
No
Required Documentation
State ID or Driver’s License
Provided
Social Security Card
Provided
Proof of Income
Provided
Medical Records
Provided
Parole/Probation Papers
Provided
Other
Signatures
Client Signature
*
Client Signature - Date
*
-
Month
-
Day
Year
Date
Staff Signature
*
Staff Signature - Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: