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Hope for homeless veterans

VTH seeks 2022 Veteran of the Year Nominations by September 15.

Nominate a Veteran

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Application for Services

INTAKE FORM

Complete the form below, or click here to download this form to submit offline (it is a fillable Word document).

Referral Date*
MM slash DD slash YYYY
Are you referring:*
- yourself
- someone else
Your Name*
First Last
Referral Source
Preferred follow up method:
- E-mail
- Phone
- Text
- Letter
Name*
First Last
Date of Birth
MM slash DD slash YYYY
Ethnicity
- Hispanic
- Caucasian
- African American
- Pacific Islander
- Asian
- American Indian
Sex
- M
- F
Social Security #
Marital Status
- Single
- Married
- Separated
- Widowed
- Divorced
Email
Phone
Current Residence
Street Address Address Line 2 City State ZIP Code
Type of Residence
- Emergency Shelter
- Hospital (psychiatric or medical)
- Rental/Owned Property
- Detox Center
- Jail/Detention Center
- Family/Friends House
- Place not meant for habitation
- Hotel/Motel (without voucher)
Currently Homeless?
- Yes
- No
At risk of losing current housing?
- Yes
- No
If Yes, reason at risk of losing current housing?
Military Information
Branch of Service
Service Dates
MM slash DD slash YYYY
Military Status
- Active Duty
- Veteran
- Reserve Component
Discharge
- Honorable
- General
- OTH
- Bad Conduct
- Dishonorable
- Other
Employment & Training
Employment Status
- Employed
- Unemployed
- Disabled
- Retired
- Student
Valid Drivers License?
- Yes
- No
Lic. #
State Issued
Income
What is Your Total Monthly Income
Sources of Cash Benefits
- Job
- Disability
- Unemployment
- State Assistance
- Pension
Sources of Non-Cash Benefits
- SNAP (Food Stamps)
- WIC
- Child Care Services
- Other
Legal
Have you been convicted of a crime
- Yes
- No
Pending charges?
- Yes
- No
Health
Mental Health History?
- Yes
- No
Mental Health Diagnosis
Medical Health History?
- Yes
- No
Medical Health Diagnosis
Substance Use History?
- Yes
- No
Drug of Choice?
History of Detox?
- Yes
- No
Most recent detox location
Most recent detox date
MM slash DD slash YYYY
How many times in detox?
Health Insurance Information
Currently Active Health Insurance
- Yes
- No
Health Insurance Company Name*
Insurance ID#*
Service Needs
Please mark all that apply.
Housing
- Rental Assistance
- Transitional Housing Placement
- HUD-VASH Voucher
- Permanent Supportive Housing Placement
- Moving Assistance
- Shelter Placement
Employment
- Job Training Programs
- Employment Opportunities
- Work Place Accommodations
Medical
- Mental Health Treatment
- Substance Abuse Treatment
- Access to Medical Care
- Medication Access
- Dental Services
Transportation
- MBTA Services
- VTA Services
- DAV Transportation Services
Benefits
- Disability Benefits (SSI/SSDI)
- VA Service Connection
- VA Pension
- Former Employer Pension
- TAFDC
- EAEDC
- Insurance Coverage
- Food Support (SNAP/WIC)
- VA Clothing Allowance
- Child Care
Education
- Scholarships
- Tuition Assistance
- Locating Schools
- Vocational Training
Other
- Financial Advice
- Legal Aid
- Social Supports
- Other

Veterans Transition House
1297 Purchase St.
New Bedford, MA 02740

PHONE: 508-992-5313
FAX: 508-999-3909
EMAIL: info@vetshouse.org

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