Vet Haven North Admissions Referral Application Form

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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Eligibility

  • Veteran must be homeless.
  • Individual must be a veteran under USDVA guidelines.
  • Veteran must be registered with the VA.
  • Applicant must be drug and alcohol free at time of admission.
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Personal Information

Gender
Have you been homeless before?
Are your dependents homeless:
Are you currently on a mortgage, deed or lease for any residential property:
Do you have healthcare insurance:
If yes, please detail the provider:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Military Information

Do you have a copy of your DD214 or a Statement of Service:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Substance Abuse Information

Do you have a history of substance abuse / dependence:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Mental Health

Do you have a history of mental health treatment:
Have you ever had thoughts of suicide:
Have you ever hurt yourself intentionally:
Have you ever had thoughts of harming others:
Have you ever attempted to severely injure another:
Do you currently have the desire and means to harm yourself or others:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Medical Issues

Have you been tested for Hepatitis:
Have you been tested for TB:
Have you been tested for HIV:
Are you receiving or do you need therapy for the above listed diagnosis:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Educational / Vocational History

Are there any medical or other issues which would preclude you from this:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Financial / Legal Issues

Do you have income (e.g. VA Disability, Employment, Unemployment, Social Security, etc.):
Have you ever been arrested for and / or convicted under Megan’s law or a similar lawagainst child molestation:
Do you have a valid Driver’s License:
Is it valid:
Do you have a CDL License:
Do you have a vehicle:
Plans to bring one to Veteran’s Haven:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Applicant Narrative

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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Attachments

Downloadable Forms:

  1. Medical Certification Form
  2. Health Release Form

 

Select the items you have to upload:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Applicant Statement:

  • I understand that, as part of the application process, I must be agreeable to provide military and medical documentation, including, but not limited to: DD214, blood work (including pregnancy test for women), urine drug screen, and tuberculosis screening (PPD).

  • I understand I must provide Veteran’s Haven North with my contact information and communicate any changes to that information, immediately, in order to facilitate my admission.

  • I understand that if I am accepted to Veteran’s Haven North, I would be provided with copies of the rules/regulations and policy and procedures, which I will be expected to follow.

  • I understand that if I am accepted to Veteran’s Haven North, I would work with the staff to establish and adhere to a treatment plan.

  • I understand that, as a resident at Veteran’s Haven North, I would be assigned collective duty assignments / chores related to the function and daily operation of the home.

  • I understand that I will need to sign release of information forms for healthcare providers, parole officers, etc. for coordination of my treatment plan.

  • I understand that, if I fail to answer application questions honestly and accurately, my admission and/or residency at Veteran’s Haven North may be affected.

  • I understand that, should I be accepted for residency at Veteran’s Haven North, my failure to meet the aforementioned expectations may also affect my residency there.

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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Policy

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