HOME ALAST
VETERAN PROGRAM INTAKE QUESTIONNAIRE
Please complete all sections as accurately as possible. This information is confidential and used solely to determine eligibility
and support requirements.
2 — MILITARY SERVICE & VETERAN STATUS
Branch of Service:
Service Start Date:
-
Month
-
Day
Year
Date
Discharge Date:
-
Month
-
Day
Year
Date
Discharge Type:
Honorable
General Under Honorable Conditions
Medical
Other / OTH
Combat Deployment:
Yes
No
(If yes, theater/operations):
3 — HOUSING DESIGNATION & PREFERENCES
Preferred Housing Type:
Transitional Housing
Permanent Supportive Housing
Independent Living
Room Preference:
Private Room
Shared / Semi-Private
Specific Accommodations:
Wheelchair / ADA Accessibility
Ground Floor Requirement
Service Animal Accommodation
4 — CURRENT HOUSING & FINANCIAL SITUATION
Current Living Situation:
Literally Homeless
Staying with Friends/Family
Temporary Shelter
Other
Monthly Net Income:
Primary Source:
Income Sources:
Employment
VA Disability Compensation
SSI / SSDI
Pension
Current Financial Assets / Savings:
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5— HEALTH, INDEPENDENCE & SUPPORT NEEDS
Physical Health Status:
Excellent
Good
Fair
Requires Routine Care
Mobility / ADL Assistance:
Fully Independent
Requires Partial Assistance
Uses Walker/Cane/Wheelchair
Mental Health / Support Needs:
PTSD Support
Substance Use Recovery
Counseling / Therapy Services
Current Medications:
6— CRIMINAL BACKGROUND DISCLOSURE
Have you ever been convicted of a felony?
Yes
No
Are you currently on probation or parole?
Yes
No
Any pending legal charges or warrants?
Yes
No
If yes to any, please briefly describe the nature and status:
7— VA BENEFITS, SERVICES & REFERRING AGENCY
Enrolled in VA Healthcare?
Yes
No
VA Medical Center Location:
Assigned VA Case Manager:
Phone/Email:
Referring Agency Name:
Contact Person:
8— COMMUNITY PARTICIPATION & PROGRAM EXPECTATIONS
Please describe your expectations for community living and goals you want to achieve through this program:
Are you willing to participate in community meetings and shared chores?
Yes
No
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9 — PERSONAL REFERENCES
Provide details for two personal or professional references (non-family preferred).
Full Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Reference 2
Full Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
10 — ADDITIONAL INFORMATION
Use this space to share any additional details, unique circumstances, or specific requests:
Applicant Signature:
Date:
-
Month
-
Day
Year
Date
Home Alast | Veteran Intake
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