Pre-Intake Application for Veteran Center services

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Pre-Intake Application for Services

Name *
Date of birth *
Phone Number *

Address *

Street Address

Address Line 2


State / Province / Region

Postal / Zip Code

How did you hear about us? *
Highest grade/degree completed: *
Military Branch *
Military Identification Number *
Are you receiving benefits? *
 If yes, how much? 
Best time(s) during the day to contact you


In your own words, please describe briefly what the problem is that you are experiencing. *
tell us what type of services you need. (You may check more than one.)
 Individual Therapy 
 Housing: Temporary/Permanent 
Please describe some of the feelings or thoughts you are (or your child is) experiencing.
(You may check more than one.)
 Crying all the time 
 Acting out in school 
 Learning problems 
 Relationship issues 
 Life adjustment/enhancement 
long have you (he/she) been feeling this way?
 Less than 1 week 
 1-2 weeks 
 6 weeks 
 3 months 
 Less than 6 months 
 Less than 1 year 
 More than 1 year 
Has anything happened recently or changed in your (his/her) life that might be related to these feelings? (You may check more than one.)
 Recent loss or death of close friend/family member 
 Change or loss in work or living situation  
Do you have any children
 If yes, how old are they? 
What do you do for a living (if a minor child, parent/guardian's occupation)?
 Full-time employed (specify) 
 Part-time employed (specify)  
 Other (specify) 
What is your current living situation?
Are you currently in a relationship
 If yes, for how long?  
Have you applied for TANF or supportive services?
 If yes, did it help?  
you (he/she) ever been in a drug or alcohol treatment program?
 If yes, when?  
you (he/she) ever been hospitalized for psychological reasons (i.e. for depression)?
 If yes, for what reason? When did this occur?  
you (he/she) ever been hospitalized for psychological reasons (i.e. for depression)?
 If yes, please list names and dosages. 
you (he/she) ever been charged or convicted of a crime (misdemeanor or felony)?
 If yes, explain. 
How many alcoholic drinks do you (he/she) have in a typical week? Please check amount:
 More than 15 
What is your (or your child's) racial or ethnic background?
Please check "Yes" or "No" for the following questions.
Do you use any street drugs or medications prescribed for someone else?
Are you ever involved in physical fights with other people?
Are you currently, or have you ever been, involved in the legal system?
Has your family ever been involved with Child Protective Service?
If you have children, have you ever lost custody of your children?
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