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.

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Personal Information

Name:

Social Security Number:

Age:

Date of Birth:

Gender

Male

Female

Non-binary

Ethnicity/Race:

Marital Status:

Have you been homeless before?

Yes

No

If yes, how many times:

Number of Dependents:

Are your dependents homeless:

Yes

No

Are you currently on a mortgage, deed or lease for any residential property:

Yes

No

Have you ever been a resident at VHN? If so, when:

List current residence / program address:

Please provide the name and phone number of the person assisting you with this application (if applicable):

Date of Discharge from program / Eviction:

List phone # where you can be reached:

Please list your personal e-mail address:

How long have you been homeless:

Last Residence (not a Half-way House/Program):

Hometown / State / County:

Do you have healthcare insurance:

Yes

No

If you aren’t currently receiving VA Healthcare benefits, are you eligible:

If yes, please detail the provider:

VA Healthcare

Medicaid

Medicare

Private Insurance

Other

Other Provider:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Military Information

Branch of Service:

Years Served:

Combat? / Where:

Overseas Duty? / Where:

MOS / Job Title:

Reason for leaving the Military:

Type of Discharge:

Do you have a copy of your DD214 or a Statement of Service:

Yes

No

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Substance Abuse Information

Do you have a history of substance abuse / dependence:

Yes

No

Drug(s) of Choice (including tobacco):

Period(s) of Use:

Last Use and Triggers:

List the types of substance abuse treatment program(s) you have attended:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Mental Health

Do you have a history of mental health treatment:

Yes

No

List any / all psychiatric diagnosis (eg: PTSD):

List any treatment you are currently receiving (therapy / outpatient / medications, etc.):

Have you experienced any traumatic event(s) you are willing to disclose at this time:

Have you ever had thoughts of suicide:

Yes

No

Have you ever hurt yourself intentionally:

Yes

No

If yes, please explain:

Have you ever had thoughts of harming others:

Yes

No

Have you ever attempted to severely injure another:

Yes

No

If yes, please explain:

Do you currently have the desire and means to harm yourself or others:

Yes

No

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Medical Issues

List any / all medical diagnosis(es) / physical problem(s):

Have you been tested for Hepatitis:

Yes

No

Result:

Have you been tested for TB:

Yes

No

Result:

Have you been tested for HIV:

Yes

No

Result:

Are you receiving or do you need therapy for the above listed diagnosis:

Yes

No

List any / all medications you are currently taking:

Please list any known allergies:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Educational / Vocational History

When did you last work:

What kind of job was it:

What vocational training have you had (include dates):

What is your highest level of education:

What would you want to do educationally and / or vocationally with your life:

Are there any medical or other issues which would preclude you from this:

Yes

No

If yes, please list:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Financial / Legal Issues

Do you have income (e.g. VA Disability, Employment, Unemployment, Social Security, etc.):

Yes

No

If yes, please list amount / source:

Do you have an application pending for Social Security Disability or Non-Service connected Pension:

Do you have any financial obligations? (e.g. child support, student loans, fines, IRS, credit cards):

List any / all legal problems (past, present, and / or pending), include dates and outcomes, not to be limited to and including the following: arrested and convicted for a crime(s), incarcerations, court appointed restitutions, been on or are on probation and / or parole, any / all outstanding warrants:

Have you ever been arrested for and convicted of assault or domestic abuse: If yes, explain (include dates and outcome(s)):

Have you ever been arrested for and / or convicted under Megan’s law or a similar laws against child molestation:

Yes

No

If yes, explain (include dates and outcome(s)):

Do you have a valid Driver’s License:

Yes

No

What State: Value is not selected

Is it valid:

Yes

No

Do you have a CDL License:

Yes

No

Issuing State: Value is not selected

Class:

Do you have a vehicle:

Yes

No

Plans to bring one to Veteran’s Haven:

Yes

No

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Applicant Narrative

List some of your strong points:

List some of your weak points:

What do you see yourself doing in the next two years:

What is the biggest obstacle to achieving your goals:

Why do you want to come to Veteran’s Haven:

What do you expect from this program:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Attachments

Downloadable Forms:

Select the items you have to upload:

Medication List

Medical Certification (DCA requirement)

Mental Health Evaluation (Current)

Physical Evaluation (Current)

Health Release Form

DD214 or Statement of Service

Upload Here:

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.

Please sign below if you meet and agree to all of the above.

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Policy

New Jersey Department of Veterans Affairs Privacy Policy
Please review the Privacy Policy.

I confirm that I have reviewed the NJ Department of Veteran Affairs Privacy Policy *

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Vet Haven North Admissions Referral Application Form

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Eligibility

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Personal Information

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Military Information

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Substance Abuse Information

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Mental Health

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Medical Issues

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Educational / Vocational History

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Financial / Legal Issues

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Applicant Narrative

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Attachments

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Applicant Statement:

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

Policy