Pre-Intake Application for Veteran Center services

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Pre-Intake Application for Services

Name *
Date of birth *
Gender
 Male 
 Female 
Phone Number *

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Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
How did you hear about us? *
Highest grade/degree completed: *
Military Branch *
Military Identification Number *
Are you receiving benefits? *
 Yes  
 No 
 If yes, how much? 
Best time(s) during the day to contact you

HH
:
MM

AM/PM
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.)
 Career 
 Assessment/Testing 
 Individual Therapy 
 Food 
 Clothing 
 Benefits/Claims 
 Housing: Temporary/Permanent 
Please describe some of the feelings or thoughts you are (or your child is) experiencing.
(You may check more than one.)
 Anger 
 Depression 
 Anxiety/Panic 
 Alcohol/Drugs 
 Fears 
 Crying all the time 
 Acting out in school 
 Learning problems 
 Confusion 
 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  
 Other 
Do you have any children
 Yes 
 No 
 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)  
 Student 
 Unemployed 
 Other (specify) 
What is your current living situation?
 Roommate(s) 
 Spouse/partner 
 Children 
 Parents 
 Single/alone 
Are you currently in a relationship
 Yes 
 No 
 If yes, for how long?  
Have you applied for TANF or supportive services?
 Yes 
 No 
 If yes, did it help?  
you (he/she) ever been in a drug or alcohol treatment program?
 Yes 
 No 
 If yes, when?  
you (he/she) ever been hospitalized for psychological reasons (i.e. for depression)?
 Yes 
 No 
 If yes, for what reason? When did this occur?  
you (he/she) ever been hospitalized for psychological reasons (i.e. for depression)?
 Yes 
 No 
 If yes, please list names and dosages. 
you (he/she) ever been charged or convicted of a crime (misdemeanor or felony)?
 Yes 
 No 
 If yes, explain. 
How many alcoholic drinks do you (he/she) have in a typical week? Please check amount:
 0-3 
 4-7 
 8-11 
  12-15 
 More than 15 
What is your (or your child's) racial or ethnic background?
 African-American 
 Asian-American 
 Hispanic 
 Caucasian 
 Other 
Please check "Yes" or "No" for the following questions.
Do you use any street drugs or medications prescribed for someone else?
 Yes 
 No 
Are you ever involved in physical fights with other people?
 Yes 
 No 
Are you currently, or have you ever been, involved in the legal system?
 Yes 
 No 
Has your family ever been involved with Child Protective Service?
 Yes 
 No 
If you have children, have you ever lost custody of your children?
 Yes 
 No 
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