Veteran Referral & Services Application Form
Share your information so we can review your request.
Basic Information
Date of Referral
*
-
Month
-
Day
Year
Date
Who is completing this referral?
*
Veteran seeking services
Family member/spouse
VA representative
Government agency
Community partner
Other
Referral Contact Name
*
First Name
Middle Name
Last Name
Relationship to Veteran
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Best way to contact you
*
Phone
Text
Email
Preferred contact time
Hour Minutes
AM
PM
AM/PM Option
Which state are you looking for services in?
*
Louisiana
Texas
Both
Unsure
Veteran Information
Veteran Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Current City
Current State
*
Please Select
Texas
Louisiana
Other
County/Parish
Preferred Service Location
Military Service Verification
Are you a Veteran?
*
Yes
No
Currently serving
Unsure
Branch of Service
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Other
Dates of Military Service
Discharge Status
Please Select
Honorable
General
Other Than Honorable
Unknown
Do you have a DD-214?
*
Yes
No
Need assistance obtaining one
Service Requested
Housing Support
Emergency housing assistance
Transitional housing
Housing stabilization support
Preventing homelessness
Help maintaining current housing
Employment Support
Job search assistance
Resume/interview help
Career training
Workforce development
Education/certifications
Mental Health & Wellness Support
Counseling support
PTSD/trauma support
Substance use recovery support
Peer support
Crisis support
Healthcare connections
Other Assistance
Transportation assistance
Food assistance
Financial literacy/budgeting
Benefits/resource navigation
Other
Housing Situation
Current housing situation
*
Currently homeless
Living in shelter
Living in vehicle
Staying temporarily with family/friends
Facing eviction
At risk of losing housing
Stable housing but needs support
Other
How long has your housing situation been unstable?
*
Less than 30 days
1–6 months
6–12 months
More than 1 year
Do you have a current lease?
*
Yes
No
Household Information
Are you supporting anyone else?
*
Spouse
Children
Other dependents
No dependents
Number of people in household
*
Employment & Financial Information
Current employment status
*
Employed full time
Employed part time
Unemployed
Retired
Unable to work currently
Monthly household income range
*
No income
Under $1,000
$1,000–$2,500
$2,500+
Current barriers to stability
*
Employment
Transportation
Mental health
Substance use recovery
Disability/health concerns
Legal issues
Lack of identification/documents
Financial challenges
Other
Urgency Assessment
Immediate need
*
Need housing within 24–72 hours
Need food assistance
Need transportation
Need mental health support
Need employment assistance
Other
Currently in crisis or experiencing thoughts of harming self or others?
*
Yes
No
Consent
Authorization to Contact Me
*
JB Housing Group may contact me regarding services and referrals
Acknowledgment
*
I understand that completing this form does not guarantee program enrollment and that eligibility will be reviewed
Submit Referral
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