Application for Services

Referral Date*

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

Ethnicity

Hispanic
Caucasian
African American
Pacific Islander
Asian
American Indian

Sex

M
F

Social Security #

Marital Status

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

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

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

Education

Scholarships
Tuition Assistance
Locating Schools
Vocational Training

Other

Financial Advice
Legal Aid
Social Supports
Other

Hope for homeless veterans

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