36C26220R0078-004.pdf

Assessment Form Worksheet (rev.10/01/2019) page 1 of 11

Homeless Services Assessment Form Worksheet

VA Staff member completing this form (first and last name)…

VA Site (3-digit VAMC code plus 2-digit suffix, if any) ……….

Date of Assessment (mm/dd/yy)………….…………...……...… / /

I. VETERAN IDENTIFICATION

2. Social Security Number ......……………...………………. - -

3. Date of Birth (mm/dd/yy) ...……………..………………… / /

4. Gender ………………..…………………...……..……..... 1. Female 2. Male

3. Transgender male to female

4. Transgender female to male

5. Gender Non-Conforming

6. Client doesn’t know

II. PRE-ENGAGEMENT SCREENING

May the Pre-engagement Screening be skipped? If yes, skip to item 6 0. No 1. Yes

5. Does the Veteran want assistance with any of the following areas?

[answer the category as “yes” if the Veteran answers “yes” to any of the informal probe questions]

a. Housing – Examples: 0. No Are you currently homeless? 1. Yes Are you currently living with a family member or friend until you can afford or find a 98. Veteran declined to answer place of your own? 99. Interviewer omitted item Have you received an eviction notice or request to leave your current housing?

b. Financial Hardship – Examples 0. No Do you need basic assistance like food and clothing? 1. Yes Are you unable to pay your bills? 98. Veteran declined to answer Do you need assistance with claims for disability benefits? 99. Interviewer omitted item Are you unemployed?

c. Legal - Examples 0. No Do you need help with a legal problem, such as civil, criminal, child support and/or 1. Yes custody, suspended driver license, probation or parole issues? 98. Veteran declined to answer

99. Interviewer omitted item

d. Access to Healthcare – Examples 0. No Are you in need of immediate medical attention or need a referral for a medical 1. Yes appointment? 98. Veteran declined to answer Do you want VA healthcare but are currently not enrolled for it? 99. Interviewer omitted item

e. Mental Health Concerns and Substance Abuse –

Examples 0. No Do you often feel anxious or depressed? 1. Yes Have you felt you wanted or needed to cut down on your drinking or drug use in 98. Veteran declined to answer the last year? 99. Interviewer omitted item

f. Self-Endangerment – Examples 0. No Do you currently have thoughts of hurting yourself in some way? 1. Yes

98. Veteran declined to answer

99. Interviewer omitted item

g. Civilian Adjustment -

1. Veteran’s Name (last name, first initial - please print)

ATTACHMENT B - Discharge Form

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Examples 0. No Are you having difficulty adjusting to civilian life since being discharged from 1. Yes military service? 98. Veteran declined to answer

99. Interviewer omitted item

6. Will the assessment interview be completed?

If yes, skip to item 7

0. No 1. Yes

a. If no, please indicate main reason:

1. Veteran will not consent to interview

2. Veteran is not interested in any services

3. Veteran is not in need of homeless program services

4. Assessment deferred to a later time

b. If no, are immediate Non-VA homeless services required? 0. No 1. Yes

If no, skip to item 6d.

c. If yes, which Non-VA homeless service is required?

1. Non-VA Emergency Room (medical or psychiatric)

0. No

1. Yes

2. Non-VA detoxification services 0. No 1. Yes

3. Non-VA mental health or substance abuse services 0. No 1. Yes

4. Non-VA medical services 0. No 1. Yes

5. Non-VA social vocational assistance 0. No 1. Yes

6. Non-VA housing 0. No 1. Yes

7. Non-VA Income Resources 0. No 1. Yes

8. Other (specify): 0. No 1. Yes

d. May we contact you at a later date?

0. No

1. Yes, in 1 month

2. Yes, in 6 months

3. Yes, in 1 year

98. Veteran declined to answer

III. ASSESSMENT INTERVIEW

7. What race do you most strongly identify with?

1. American Indian or Alaskan Native 5. White

2. Asian 6. Don’t know

3. Black or African American 98. Veteran declined to answer

4. Native Hawaiian or Other Pacific Islander 99. Interviewer omitted item

8. What ethnicity do you most strongly identify with?

0. Non-Hispanic/Non-Latino 98. Veteran declined to answer

1. Hispanic/Latino 99. Interviewer omitted item

2. Don’t know

9. What is your current marital status? (choose most recent marital status)

1. Married 4. Separated 7. Committed relationship/partnered

2. Remarried 5. Divorced 98. Veteran declined to answer

3. Widowed 6. Never married 99. Interviewer omitted item

10. How many children under the age of 18 do you have? Include biological children, adopted children, stepchildren, and foster children. (If no children, code 0; if Veteran refused or interviewer omitted, code N)

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a. How many of them are in your legal custody (full or joint custody)?

11. How many full years of formal education do you have? (if refused to answer code N)

Guidelines: Use the following to help determine number of completed years. If any years of graduate or professional education have been completed, enter 20 years).

Elementary-Middle-High School Junior/Comm/4-year College Grad/Professional

1- 2- 3- 4- 5- 6- 7- 8- 9- 10- 11- 12 13- 14- 15 -16 Enter 20

IV. MILITARY HISTORY

12. Identify the years in whi served; if equal time in t ch you entered and separated from military service (favor the longest period of time wo separate episodes, favor a combat era over a non-combat era). (Code N if unknown)

a. What year did you enter military service?

b. What year did you sepa ate from military service?

13. In which branch of the military did you serve the longest?

1. Army 4. Air Force 98. Veteran declined to answer

2. Navy 5. Coast Guard 99. Interviewer Omitted Item

3. Marines

14. In which component of the military did you serve the longest?

1. Active Duty (Regular) 3. Reserves 99. Interviewer Omitted Item

2. National Guard 98. Veteran declined to answer

15. What was the rank status of your longest military service?

1. Enlisted 3. Commissioned Officer 99. Interviewer Omitted Item

2. Warrant Officer 98. Veteran declined to answer

16. What was the highest rank you achieved during your military tour(s) of duty?

[E-rating of 1-9 for enlisted; W-rating of 1-5 for Warrant Officer; C-rating of 1-10 for Commissioned Officer; enter N if unknown or Veteran declined to answer]

17. Are you currently serving in the military on active duty or active in the Reserves or National Guard?

0. No 2. Active in Reserves 98. Veteran declined to answer

1. Active duty in military 3. Active in National Guard 99. Interviewer Omitted Item

18. Did you serve in the the

This item asks about se tre of operations for any of the following military conflicts?

vice within the geographic proximity of the military conflict, not participation in combat.

a. World War II 0. No

1. Yes

98. Veteran declined to answer

99. Interviewer omitted item

b. Korean War 0. No

1. Yes

c. Vietnam War

98. Veteran declined to answer

99. Interviewer omitted item

d. Persian Gulf War ( Operation Desert Storm) 0. No

1. Yes

98. Veteran declined to answer

99. Interviewer omitted item

e. Afghanistan (Operat ion Enduring Freedom) 0. No

1. Yes

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f. Iraq (Operation Iraqi Freedom) 0. No

98. Veteran declined to answer

99. Interviewer omitted item

g. Iraq (Operation New Dawn) 0. No

1. Yes

98. Veteran declined to answer

99. Interviewer omitted item

h. Other peace-keeping operations or military interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo)

0. No

1. Yes

19. Did you ever receive hostile or friendly fire in a combat zone? 0. No

V. LIVING SITUATION

20. Where were you residing prior to today (ask the Veteran where he/she slept last night)?

Select if Veteran declined to answer or interviewer omitted item:

If Veteran declined or interviewer omitted item, skip to item 24

1. Housing owned by Veteran, no ongoing housing subsidy

2. Housing owned by Veteran, with ongoing housing subsidy

3. Housing rented by Veteran, no ongoing housing subsidy

4. Housing rented by Veteran with HUD-VASH voucher

5. Housing rented by Veteran with non-HUD-VASH housing subsidy

6. Permanent housing for formerly homeless persons (such as: CoC project or S+C)

7. Staying or living with family, permanent tenure

8. Staying or living with family, temporary tenure

9. Staying or living with friends, permanent tenure

10. Staying or living with friends, temporary tenure

11. GPD transitional housing

12. Non-VA transitional housing for homeless persons

13. VA MH RRTP

14. CWT/TR

15. Non-VA residential treatment program

16. Non-VA substance abuse treatment facility or detox center

17. Hospital or other residential non-psychiatric medical facility

18. Long-term care facility or nursing home

19. Psychiatric hospital or other psychiatric facility

20. Prison or jail

21. VA contracted residential treatment programs (HCHV Contract Residential Services)

22. Safe Haven (SH)

23. Hotel or motel paid for without emergency shelter voucher

24. Emergency shelter (ES), including hotel or motel paid for with emergency shelter voucher

25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway, station/airport or anywhere outside)

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Specify subsidy type:

1. Mainstream (non-HUD-VASH) Housing Choice Voucher

2. Public Housing Unit, such as housing fully funded or subsidized by HUD

3. SSVF Rapid Rehousing (RRH) or equivalent RRH subsidy

4. Other subsidized housing, including locally-funded subsidized housing

21.

Over the past 30 days, did you spend at least one night in a place not meant for habitation? (e.g., a vehicle, an abandoned building, bus/train/subway, station/airport or anywhere outside).

Code “98” if Veteran declined to answer. Code “99” if interviewer omitted item.

0. No

1. Yes

98. Veteran declined to answer

99. Interviewer omitted item

21a

How long did you stay in the location where you were residing prior to today (location where he/she slept last night, item 20)?

0. One day or less 4. More than three months, but less than one year

1. Two days to one week 5. One year or longer

2. More than one week, but less than one month 98. Veteran declined to answer

3. One to three months 99. Interviewer omitted item

22. What is the zip code of that location (if unknown, use current location)?

23. Are you living with others at this location? 0. No 1.Yes 98.Veteran decline to answer 99.Interviewer omitted item

If yes, does the household include:

23a. spouse / significant other? 0. No 1.Yes

23b. children under 18 (list number)?

23c. related adults (list number)?

23d. unrelated adults (list number)?

23e. What is your relationship to the head of household at that location?

0. Self (head of household) 4. Other: non-relation member

1. Head of household’s child 98. Veteran declined to answer

2. Head of household’s spouse or partner 99. Interviewer omitted item

3. Head of household’s other relation member (other relation to head of household)

24. Housing stability: How would you describe your current housing situation?

1. Literally homeless 5. Don’t know

2. Imminent risk of losing housing 98. Veteran declined to answer

3. Unstably housed/at risk of losing housing 99. Interviewer omitted item

4. Stably housed

If item 24 = literally homeless, answer item 25; otherwise, skip to item 26.

25. How long have you been homeless?

1. At least one nigh but less than one month 5. Two years or more

2. At least one mon h but less than 6 months 6. Unknown

3. At least 6 months but less than 1 year 98. Veteran declined to answer

4. At least one year but less than 2 years 99. Interviewer omitted item

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26. What is the total number of times you have been homeless on the street, in Emergency Shelter (ES), or Safe Haven (SH), in the past three years?

0. 0 3 3. 3 98. Veteran declined to answer

1. 1 4. 4 or more 99. Interviewer omitted item

2. 2

26a. How many months in total have you been homeless in the past three years?

NOTE: If a Veteran is homeless for any part of a given month, round up and count that period as one month of homelessness. (if unknown, code N).

VI. EMPLOYMENT AND INCOME

28. Which best describes your em ployment pattern in the last 3 years?

0. Disabled or Retired 6. Other vocational training

1. Unemployed 7. Unpaid volunteer

2. Actively Seeking Emp loyment 8. Student

3. Part-time or temporar y employment 9. Don’t know

4. Full-time employment 98. Veteran declined to answer

5. VA’s IT or CWT (VI) ( IPS/SE and CBSE are c

NOTE: include CWT/TW only. 99. Interviewer omitted item onsidered employment.)

29. How many days did you work for pay in the past 30 days?

Count participation in CWT/SE as days worked.

If none, enter 0; If Veteran declined to answer, code N.

30. Did you receive any money in the past 30 days?

If 30 = no, Veteran declined to answer, or interviewer omitted item, skip to item 31.

If yes, list amount below in each category

1.Yes

Please round to whole dollar amounts and note comma placement (e.g., $452.76 should be entered as $453.00)

a. Employment (include CWT/SE) $ , . 0 0

b. Compensation for service connected psychiatric condition $ , . 0 0

c. Compensation for other service connected condition $ , . 0 0

d. Non-service connected pension $ , . 0 0

e. Retirement income from Social Security $ , . 0 0

f. Pension from a former job $ , . 0 0

g. Supplemental Security Income (SSI) $ , . 0 0

h. Social Security Disability Income (SSDI) $ , . 0 0

i. Private disability insurance $ , . 0 0

j. Worker’s compensation $ , . 0 0

k. Unemployment insurance $ , . 0 0

l. Temporary Assistance for Needy Families (TANF) or similar local program $ , . 0 0

m. General Assistance (GA) or similar local program $ , . 0 0

n. Child support $ , . 0 0

o. Alimony or other spousal support $ , . 0 0

p. All other sources (do not include food stamps) $ , . 0 0 Total Income Total Income Calculated in HOMES

27.

What is the total amount of time, if any, that you have spent in jail or prison during your lifetime?

0. None 2. Between 1 month and 1 year 98. Veteran declined to answer

1. Less than 1 month 3. More than 1 year 99. Interviewer omitted item

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31. Did you receive any non-cash benefits in the past 30 days?

If 31 = no, Veteran declined to answer, or Interviewer omitted item, skip to item 32

If yes, select each category:

1.Yes

a. Medicaid health insurance program or similar local program 0. No 1. Yes

b. Medicare health insurance program or similar local program 0. No 1. Yes

c. Temporary Rental Assistance 0. No 1. Yes

d. Homeless Prevention and Rapid Re-Housing Program (HPRP) Funds 0. No 1. Yes

e. Veteran Service Organizations 0. No 1. Yes

f. State Children’s Health Insurance Program or similar local program 0. No 1. Yes

g. Supplemental Nutrition Assistance Program (SNAP) or Food Stamps 0. No 1. Yes

h. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) 0. No 1. Yes

i. Temporary Assistance for Needy Families (TANF) or similar local program Child Care Services 0. No 1. Yes

j. Temporary Assistance for Needy Families (TANF) or similar local program Transportation Services

0. No 1. Yes

k. Other TANF-funded services 0. No 1. Yes

l. Bus, subway, train or cab voucher 0. No 1. Yes

m. SSI/SSDI Outreach, Access and Recovery (SOAR) 0. No 1. Yes

n. Other (specify) 0. No 1. Yes

32. Do you have any significant outstanding debts?

If yes, please specify debt sources:

1.Yes 98.Veteran decline to answer 99.Interviewer omitted item

a. Housing loans 0. No 1.Yes

b. Student loans 0. No 1. Yes

c. Other loans (personal, auto, etc.) 0. No 1. Yes

d. Credit card debt 0. No 1. Yes

e. Child support 0. No 1. Yes

f. Alimony 0. No 1. Yes

g. Medical expenses (self or dependents) 0. No 1. Yes

h. Fines or other legal obligations 0. No 1. Yes

i. Outstanding tax bills 0. No 1. Yes

j. Other (specify) 0. No 1. Yes

33. Do you currently have a representative payee or fiduciary? 0. No

98. Veteran decline to answer

VII. CLINICAL STATUS

34. In the past 30 days, would you say your physical health has been:

0. Excellent 3. Fair 98. Veteran declined to answer

1. Very Good 4. Poor 99. Interviewer omitted item

2. Good

34a. In the past six months, how many times have you been to the emergency department/room? (if unknown, code N).

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34b. In the past six months, how many times have you been hospitalized as an inpatient, including hospitalizations in a mental health hospital? (if unknown, code N).

35. How would you describe the health of your teeth and gums?

0. Excellent

1. Very Good

3. Fair

4. Poor

98. Veteran declined to answer

2. Good

36. Has a doctor or nurse ever told you that you have any of the following medical conditions?

1. Yes

98. Veteran decline to answer

a. HIV/AIDS 0. No

98. Veteran decline to answer

99. Interviewer omitted item

b. Hepatitis C 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

c. Tuberculosis (TB) or + PPD 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

d. Chronic Obstructive Pulmonary Disease (COPD) 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

e. Heart disease 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

f. Stroke 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

g. Diabetes 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

h. Seizures 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

i. Chronic Pain 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

j. Liver disease, Cirrhosis, or End-Stage Liver Disease 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

k. Kidney Disease/End-stag. Renal Disease 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

l. History of frostbite, immersion foot or hypothermia 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

m. Cancer 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

n. History of Heat Stroke/Heat Exhaustion 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

o. Developmental Disability 0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

p. Other (specify): 0. No

1. Yes

36p. **36p IS NOT SELF-REPORT FROM THE VETERAN AND IS BASED ON THE INTERVIEWER’S IMPRESSION. **

Is this Veteran a homeless individual with a disabling condition based on one of more of the following: A physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury that: (1) Is expected to be long-continuing or of indefinite duration; (2) Substantially impedes the individual’s ability to live independently; and (3) Could be improved by the provision of more suitable housing conditions.

1.Yes

Assessment Form Worksheet (rev.10/01/2019) page 9 of 11

37. Do you use tobacco products?

38. In the past 30 days, how many days did you drink ANY alcohol?

[code N if Veteran declined or interviewer omitted]

0. No

1. Yes

39. In the past 30 days, how many days did you have at least 5 drinks (if you are a man) or at least 4 drinks (if you are a woman)?

[One drink is considered one shot of hard liquor (1.5oz) or 12-ounce can/bottle of beer or 5-ounce glass of wine] [code N if Veteran declined or interviewer omitted]

40. In the past 30 days, how many days did you use any illegal/street drugs or abuse any prescription medications?

[code N if Veteran declined or interviewer omitted] Examples: marijuana purchased illegally and not prescribed for medicinal purposes; heroin or methadone; barbiturates (downers); cocaine or crack;

amphetamines (speed); hallucinogens, like acid; or inhalants, like glue, paint or nitrous oxide.

41. In the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs?

0. Not at all 3. Considerably 98. Veteran declined to answer

1. Slightly 4. Extremely 99. Interviewer omitted item

2. Moderately

42. Have you ever received professional treatment for alcohol or other substance use disorder?

0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

43. Have you ever been hospitalized for a psychiatric problem?

(do not include residential treatment or hospitalization for a substance use problem)

0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

44. Have you been attacked or beaten up since you’ve become homeless?

0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

45. Have you threatened to or tried to harm yourself or anyone else in the last year?

0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

46. Does anybody force you or trick you to do things you do not want to do?

0. No

1. Yes

98. Veteran decline to answer

99. Interviewer omitted item

47. Do you ever do things that may be considered to be risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don’t know, share a needle, or anything like that?

0. No

1. Yes

[END OF INTERVIEW QUESTIONS]

VIII. CLINICAL IMPRESSIONS

48. Which of the following treatment concerns apply to this Veteran:

a. Alcohol use disorder 0. No 1. Yes

b. Drug use disorder 0. No 1. Yes

c. Gambling problem or pathological gambling 0. No 1. Yes

d. Schizophrenia 0. No 1. Yes

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e. Other psychotic disorder 0. No 1. Yes

f. Bipolar disorder 0. No 1. Yes

g. Military related PTSD 0. No 1. Yes

h. Non-Military related PTSD 0. No 1. Yes

i. Anxiety disorder 0. No 1. Yes

j. Affective disorder (including depression) 0. No 1. Yes

k. Adjustment disorder 0. No 1. Yes

l. Nicotine dependence 0. No 1. Yes

m. Organic brain syndrome 0. No 1. Yes

n. Personality disorder 0. No 1. Yes

o. Other psychiatric disorder 0. No 1. Yes

49a. D oes this Veteran need psychiatric treatment at this time? 0. No 1. Yes

49 b. Is the Veteran interested and willing to participate in psychiatric treatment?

0. No 1. Yes 2. Don’t know

50a. D oes this Veteran need substance abuse treatment at this time? 0. No 1. Yes

50 . Is the Veteran interested and willing to participate in substance abuse

51a. D oes this Veteran need medical treatment at this time? 0. No 1. Yes

51 . Is the Veteran interested and willing to participate in medical treatment? 0. No 1. Yes 2. Don’t know

52a. D oes this Veteran need case management? 0. No 1. Yes

52 . Is the Veteran interested and willing to participate in case management

53a. D oes the Veteran need assistance with family problems? 0. No 1. Yes

53 . Is the Veteran interested and willing to participate in treatment for family problems?

54. Is this Veteran a danger to self or others? 0. No 1. Yes

55. Is this Veteran in danger from others (i.g., gang violence, fleeing domestic violence)?

IX. INTERVIEWER INFORMATION

56. Main program affiliation of interviewer:

1. HUD-VA Supportive Housing (HUD-VASH)

2. Healthcare for Homeless Veterans (HCHV)

3. Grant and Per Diem (GPD)

4. VA MH RRTP [Includes all types - DCHV, CWT/TR, SA RRTP; PTSD RRTP; General RRTP]

5. Healthcare for Re-entry Veterans (HCRV)

6. Veterans Justice Outreach (VJO)

7. Other: VA affiliation

57. How was contact for this interview initiated?

By VA:

1. Street outreach initiated by VA staff

2. Justice System outreach initiated by VA staff

3. Other community outreach by VA staff

4. Contacted at Stand Down

5. Referral from VA MH RRTP [Includes all types - DCHV, CWT/TR, SA RRTP; PTSD RRTP; General RRTP]

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6. Referral from VA mental health outpatient unit

7. Referral from VA substance abuse outpatient unit

8. Referral from VA medical outpatient unit

9. Referral from VA Emergency Room

10. Referral from VA inpatient unit

11. Referral from Vet Center

12. Referral from VBA

13. Referral from VA Homeless Veterans Hotline (1-877-424-3838)

By non-VA:

14. Street outreach by non-VA staff

15. Referral by shelter staff or other community homeless services provider

16. Referral from VA Grant and Per Diem

17. Referral from Non-VA Emergency Room

18. Referral from Non-VA Community Mental Health Center or clinic

19. Referral from other Federal Agency (HUD, Dept. of Labor, HHS)

By Criminal Justice System:

20. Referred by jail or prison staff

21. Referred by law enforcement official

22. Referred by Court (judge or District Attorney)

23. Referred by an attorney (e.g., public defender or defense attorney)

24. Referred by probation/parole officer

By family, self or other:

25. Referred by family member

26. Self-referred

27. Other: (please specify)

If item 25 = 4 or 5 and item 36p = yes; OR if item 26 = 4, and item 26a = 12 or more, and 36p = yes, complete the following:

Based on the information you provided, this Veteran is chronically homeless. Will you be documenting a referral to HUD-

VASH?

0. No

1. Yes

If no, please indicate the most appropriate reason why this Veteran who in chronically homeless is not being referred to

HUD-VASH.

1. Lifetime registered sexual offender, per the PHA.

2. Veteran is over income, per the PHA.

3. All vouchers are currently in use in the desired location where the Veteran wants to live.

4. Current staffing does not allow for new admissions.

5. Veteran has other housing options available that are preferable to him/her (family reconciliation, community housing program).

6. Veteran declines offer of admission.

7. Veteran needs a higher level of clinical care and cannot live independently.

8. Veteran is not eligible for VHA services.

9. Others with higher acuity given priority for referral.

10. Referral pending coordinated entry system review.

HOMES Referral Form (rev.10/1/2019) Page 1 of 4

Homeless Operations Management and Evaluation System (HOMES) Referral Form

NOTE: Programs in which Veteran is already enrolled or for which referral is pending are not available for new referral on this form.

VA Staff Login (first and last name)

VA Site (3-digit VAMC code plus 2-digit suffix, if any)

I. VETERAN IDENTIFICATION

1. Veteran’s name (last name, first initial)………

2. Social Security number ....…………………...………………. - -

3. Date of birth (mm/dd/yy) ...…………………………………… / /

4.

Gender………………………………………...……..……

1. Female, 2. Male, 3. Transgender male to female,

4. Transgender female to male, 5. Gender Non- Conforming, 6. Client doesn’t know

II. REFERRAL PLANS

VA Specialized Homeless Services:

5 Case Management Services

a. HUD-VASH Case Management Services (intensive case management with permanent housing)

0. None

2. Would make referral, but no vouchers available

If yes, or if the Veteran is NOT chronically homeless based the current HOMES Assessment, skip to item 5b; if no and the Veteran IS chronically homeless based on the current HOMES Assessment, complete the following item.

Based on information provided on the current Assessment, this Veteran is determined to be chronically homeless.

Please indicate the most appropriate reason why the Veteran is not being referred to HUD-VASH at this time.

1. Lifetime registered sexual offender, per the PHA.

2. Veteran is over income, per the PHA.

3. All vouchers are currently in use in the desired location where the Veteran wants to live.

4. Current staffing does not allow for new admissions.

5. Veteran has other housing options available that are preferable to him/her (family reconciliation, community housing program).

6. Veteran declines offer of admission.

7. Veteran needs a higher level of clinical care and cannot live independently.

8. Veteran is not eligible for VHA services.

9. Others with higher acuity given priority for referral.

10. Referral pending coordinated entry system review.

b. HCHV Case Management Services (direct case management beyond referral to other services)

0. None

6. Residential treatment / transitional housing

1. HCHV Contracted Emergency Residential Services (CERS)

2. HCHV Low Demand Safe Haven (LDSH)

3. GPD Transitional Housing

6. Other MH RRTP residential treatment (e.g., SA RRTP, PTSD RRTP, General RRTP)

HOMES Referral Form (rev.10/1/2019) Page 2 of 4

What is the status of the referral to other MH RRTP residential treatment?

1. Referral made and service initiated – no further follow-up needed.

2. Referral made; will continue monitoring of care

6a-f Were referrals to any of the following programs not made because beds were unavailable?

a. HCHV Contracted Emergency Residential Services (CERS)

b. HCHV Low Demand Safe Haven (LDSH)

c. GPD transitional housing

f. Other MH RRTP residential treatment (e.g., SA RRTP, PTSD RRTP, General RRTP)

7. Services for Justice-Involved Veterans:

1. Veterans Justice Outreach (VJO)

2. Healthcare for Re-entry Veterans (HCRV)

8. VA prevention services

a. HUD-VA Pilot

0. No

b. Supported Service for Veterans Families (SSVF)

c. Rapid Rehousing

VA treatment services

9.

Community Resource and Referral Center

(CRRC)

0. No

10.

Homeless Patient Aligned Care Team

(HPACT)

0. No

11.

VA Emergency Room (medical or psychiatric)

12.

VA detoxification services

13.

VA mental health or substance abuse services

HOMES Referral Form (rev.10/1/2019) Page 3 of 4

14.

VA medical services

15.

VA vocational rehabilitation programs (including VA CWT/SE)

0. No

16. VBA Services a.

Disability compensation b.

Pension benefits c.

Education d.

Loan guaranty e.

Vocational rehabilitation and employment f.

Insurance

Non-VA services

17.

Basic services (e.g., food, clothing, transportation)

0. No

18.

Non-VA housing

19.

Non-VA social vocational assistance

1. Referral made and service initiated – no further follow-up needed.

20. Non-VA income resources and non-cash benefits

a. SSI or SSDI

b. TANF

c. Food Stamps or SNAP

d. GA (General Assistance)

HOMES Referral Form (rev.10/1/2019) Page 4 of 4

e. WIC

Non-VA Emergency Room (medical or psychiatric)

0. No

22.

Non-VA detoxification services

23.

Non-VA mental health or substance abuse services

0. No

24.

Non-VA medical services

HUD-VASH Entry Worksheet (rev.10/01/2019) Page 1 of 3

HUD-VASH Entry Worksheet

Staff Login (first and last name) ..……

VA Site (3-digit VAMC code plus 2-digit suffix, if any) ………….

Date this form completed (mm/dd/yy)……………..…...……...… / /

Veteran’s name (last name, first initial)…………………

Social Security number………………...……………….. - -

Date of birth (mm/dd/yy)………………………………… / /

1. Did the Veteran enter the HUD-VASH program? 0. No 1. Yes

2. Date Veteran entered HUD-VASH Case Management (mm/dd/yy)

If the Veteran did not enter the HUD-VASH program, answer item 3 only (do not complete remainder of form).

3. Select the main reason why Veteran did not enter the HUD-VASH program: (if more than one reason, code most important):

1. Veteran not interested in program (e.g. found alternate housing)

2. Veteran left; can no longer locate

3. Veteran refused to agree with the terms of the HUD-VASH program

4. Since referral, Veteran became too ill to participate

5. Veterans with greater clinical need given priority for entry over this Veteran

6. Veteran is incarcerated

7. Veteran did not meet program eligibility requirements

8. Program is not accepting new entries at this time

9. Other (specify):

4. What was the Veteran’s housing status prior to program entry (location where the Veteran was sleeping prior to program entry)?

3. Housing rented by Veteran, no ongoing housing subsidy

4. Housing rented by Veteran with HUD-VASH voucher

5. Housing rented by Veteran with non-HUD-VASH housing subsidy

6. Permanent housing for formerly homeless persons (such as: CoC project or S+C)

7. Staying or living with family, permanent tenure

8. Staying or living with family, temporary tenure

9. Staying or living with friends, permanent tenure

10. Staying or living with friends, temporary tenure

11. GPD transitional housing

12. Non-VA transitional housing for homeless persons

13. VA MH RRTP

14. CWT/TR

15. Non-VA residential treatment program

16. Non-VA substance abuse treatment facility or detox center

HUD-VASH Entry Worksheet (rev.10/01/2019) Page 2 of 3

17. Hospital or other residential non-psychiatric medical facility

18. Long-Term care facility or nursing home

19. Psychiatric hospital or other psychiatric facility

20. Prison or jail

21. VA contracted residential treatment programs (HCHV Contract Residential Services)

22. Safe Haven (SH)

23. Hotel or motel paid for without emergency shelter voucher

24. Emergency shelter (ES), including hotel or motel paid for with emergency shelter voucher

25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside) Specify subsidy type:

1. Mainstream (non-HUD-VASH) Housing Choice Voucher

2. Public Housing Unit, such as housing fully funded or subsidized by HUD

5. How long did the Veteran stay in the location where he/she was residing prior to today (location where the Veteran was sleeping prior to program entry)?

0. One day or less 5. One year or longer

1. Two days to one week 6. Don’t know

2. More than one week, but less than one month 98. Veteran declined to answer

3. One to three months 99. Omitted item

4. More than three months, but less than one year

6. Was the Veteran living with others at that location? 0. No

99.Omitted item

6a. spouse / significant other? 0. No 1.Yes 6b. children under 18 (list number)?

6c. related adults (list number)?

6d. unrelated adults (list number)?

7. How many months in total has the Veteran been homeless in the past three years? NOTE: If a Veteran is homeless for any part of a given month, round up and count that period as one month of homelessness (if unknown, code N).

8. What is the total number of times the Veteran has been homeless on the street, in Emergency Shelter (ES), or Safe Haven (SH), in the past three years?

0. Zero 4. Four or more

1. One time 5. Don’t know

2. Two times 99. Omitted item

3. Three times

9. Is this Veteran a homeless individual with a disabling condition based on one or more of the following: A physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury that: 1) Is expected to be long-continuing or of indefinite duration; (2) Substantially impedes the individual’s ability to live independently; and (3) Could be improved by the provision of more suitable housing conditions?

HUD-VASH Entry Worksheet (rev.10/01/2019) Page 3 of 3

10. What is the zip code of that location where the Veteran was residing prior to program entry (if unknown, use current location)?

HUD-VASH Housing Progress Worksheet (rev.10/01/2019) Page 1 of 4

HUD-VASH Housing Progress Worksheet

Staff member completing this form (first and last name) ..……

Sequence Number …………………...

I. VETERAN IDENTIFICATION

Veteran’s name (last name, first initial)…

Does the Veteran’s current HUD-VASH case management episode retain ho previous HUD-VASH episode? (Select “yes” only if the Veteran is using the and the housing process dates are the same as the previous HUD-VASH ep using from a 0. No same voucher 1. Yes isode.

PHA Number ……………………………………………………..

II. HOUSING PROGRESS DATES

1.

Date referral package was forwarded to the PHA (mm/dd/yy)

2. Date voucher was issued by the PHA (mm/dd/yy) / /

2a. Type of Voucher

If 2a=2, complete item 2b; if 1, skip to item 3.

2b. Project Name

1.Tenant Based Voucher 2.Project Based Voucher

3. Date housing selected by the Veteran (mm/dd/yy) / /

4. Date of Safety Inspection (mm/dd/yy) / /

5. Date Housing Assistance Payment (HAP) Contract signed (mm/dd/yy) / /

6. Date Veteran moved into HUD-VASH housing (mm/dd/yy) / /

7. What was the Veteran’s housing arrangement prior to move-in to HUD-VASH housing (location where the Veteran was sleeping prior to move- in to HUD-VASH housing)?

1. Housing owned by Veteran, no ongoing housing subsidy

2. Housing owned by Veteran, with ongoing housing subsidy

3. Housing rented by Veteran, no ongoing housing subsidy

4. Housing rented by Veteran with HUD-VASH voucher

5. Housing rented by Veteran with non-HUD-VASH housing subsidy

6. Permanent housing for formerly homeless persons (such as CoC project or S+C)

7. Staying or living with family, permanent tenure

8. Staying or living with family, temporary tenure

9. Staying or living with friends, permanent tenure

10. Staying or living with friends, temporary tenure

11. GPD transitional housing

HUD-VASH Housing Progress Worksheet (rev.10/01/2019) Page 2 of 4

12. Non-VA transitional housing for homeless persons

13. VA MH RRTP

14. CWT/TR

15. Non-VA residential treatment program

16. Non-VA substance abuse treatment facility or detox center

17. Hospital or other residential non-psychiatric medical facility

18. Long-term care facility or nursing home

19. Psychiatric hospital or other psychiatric facility

20. Prison or jail

21. VA contracted residential treatment programs (HCHV Contract Residential Services)

22. Safe Haven (SH)

23. Hotel or motel paid for without emergency shelter voucher

24. Emergency shelter (ES), including hotel or motel paid for with emergency shelter voucher

25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station or anywhere outside)

2. Public Housing Unit, such as housing fully funded or subsidized by HUD

8. How long did the Veteran st

(location where the Veteran ay in the location where he/she was residing prior to move-in to HUD-VASH housing was sleeping prior to move in to HUD-VASH housing)?

0. One day or less 4. More than three months, but less than one year

1. Two days to one w eek 5. One year or longer

2. More than one we ek, but less than one month 6. Don’t know

3. One to three month s 99. Omitted item

9. Is the Veteran living with others at that location? 0. No

9a. spouse / significant other? 0. No 1. Yes 9b. children under 18 (list number)?

9c. related adults (list number)?

9d. unrelated adults (list number)?

11.

What is the total number of time you have been homeless on the street, in Emergency Shelter (ES), or Safe Haven (SH) in the past three years?

0. Zero 3. Three times 99. Omitted item

1. One time 4. Four or more times

2. Two times 5. Don’t know

12. Is this Veteran a homeless individual with a disabling condition based on one of more of the following: A physical, mental, or emotional impairment, including an impairment caused by alcohol or drug abuse, post-traumatic stress disorder, or brain injury that: (1) Is expected to be long-continuing or of indefinite duration; (2) Substantially impedes the individual’s ability to live independently; and (3) Could be improved by the provision of more suitable housing conditions.

0. No

1. Yes

10. How many months in total have you been homeless in the past three years?

NOTE: If a Veteran is homeless for any part of a given month, round up and count that period as one month of homelessness. (if unknown, code N).

HUD-VASH Housing Progress Worksheet (rev.10/01/2019) Page 3 of 4

13. What is the zip code of that location (if unknown, use current location)?

III. CHANGE IN VOUCHER STATUS

Complete this section when there is a change in the Veteran’s voucher status. Completing this section will close the current housing episode and a new Housing Progress Form must be completed to document any subsequent housing episode.

14. Please select the reason the Veteran’s voucher status has changed.

1. Voucher was denied by the PHA

2. Voucher was revoked or expired

3. Voucher was ported locally (same medical center, different housing and different PHA)

4. Voucher was administratively absorbed by a new PHA (ported), HOWEVER Veteran retained HUD-VASH housing (same medical center, same housing, different PHA)

5. Veteran left HUD-VASH housing but maintained voucher

6. HUD-VASH voucher converted to a mainstream Housing Choice Voucher (Veteran or Veteran and family)

7. HUD-VASH voucher converted to a mainstream Housing Choice Voucher (Veteran family only)

8. Voucher was returned to the PHA by the Veteran

14a. Date voucher status changed (mm/dd/yy) / /

15. What is the Veteran’s housing arrangement at move-out from HUD-VASH housing (location where the Veteran was sleeping on the night of move-out from HUD-VASH housing)?

1. Housing owned by Veteran, no ongoing housing subsidy

2. Housing owned by Veteran, with ongoing housing subsidy

3. Housing rented by Veteran, no ongoing housing subsidy

4. Housing rented by Veteran with HUD-VASH voucher

5. Housing rented by Veteran with non-HUD-VASH housing subsidy

6. Permanent housing for formerly homeless persons (such as CoC project or S+C)

7. Staying or living with family, permanent tenure

8. Staying or living with family, temporary tenure

9. Staying or living with friends, permanent tenure

10. Staying or living with friends, temporary tenure

11. GPD transitional housing

12. Non-VA transitional housing for homeless persons

13. VA MH RRTP

14. CWT/TR

15. Non-VA residential treatment program

16. Non-VA substance abuse treatment facility or detox center

17. Hospital or other residential non-psychiatric medical facility

18. Long-term care facility or nursing home

19. Psychiatric hospital or other psychiatric facility

20. Prison or jail

21. VA contracted residential treatment programs (HCHV Contract Residential Services)

22. Safe Haven (SH)

23. Hotel or motel paid for without emergency shelter voucher

24. Emergency shelter (ES), including hotel or motel paid for with emergency shelter voucher

25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station or anywhere

26. Don’t know

HUD-VASH Housing Progress Worksheet (rev.10/01/2019) Page 4 of 4

2. Public Housing Unit, such as housing fully funded or subsidized by HUD

16. What is the zip code of that location (if unknown, use current location)?

HUD-VASH Exit Worksheet (rev.10/01/2019) Page 1 of 5

HUD-VASH Exit Worksheet

Staff member completing this form (first and last name)

I. Veteran Information

1. Veteran’s name (last name, first initial)…………………

2. Social Security number………………...……………….. - -

3. Date of birth (mm/dd/yy)………………………………… / /

II. Reasons for Program Exit

4. Date the Veteran exited the HUD-VASH program (mm/dd/yy): / /

5. Which is the most important reason why the Veteran ended involvement in HUD-VASH Case Management?

1. Veteran accomplished his/her goals and/or obtained access to services and no longer has a need for this program

2. Veteran transferred to another HUD-VASH program site

3. Veteran found/chose other housing

4. Veteran did not comply with HUD-VASH case management

5. Veteran was evicted from his/her HUD-VASH apartment by PHA or landlord and/or had other housing related issues or problems

6. Veteran unhappy with HUD-VASH housing

7. Veteran is no longer financially eligible for a HUD-VASH voucher

8. Veteran is no longer interested in participating in this program

9. Veteran cannot be located

10. Veteran too ill to participate in HUD-VASH at this time

11. Veteran is incarcerated

12. Veteran is deceased

5a. Did another household member of the deceased Veteran continue to use the voucher?

6. What is the status of the Veteran’s HUD-VASH voucher?

1. Veteran will continue to use the voucher

2. Other household member will continue to use the voucher (victim of domestic violence, etc.)

3. Veteran exited the program prior to voucher receipt

4. Voucher was denied by PHA

5. Voucher expired

6. Voucher was returned to the PHA by the Veteran

7. Voucher was revoked

8. HUD-VASH Voucher was converted to a mainstream Housing Choice Voucher (Veteran or Veteran and Family)

9. HUD-VASH Voucher was converted to a mainstream Housing Choice Voucher (Veteran Family Only)

III. Status at Program Exit

7. What is the Veteran’s housing arrangement at program exit (location where the Veteran was sleeping on the night of program exit)?

1. Housing owned by Veteran, no ongoing housing subsidy

3. Housing rented by Veteran, no ongoing housing subsidy

HUD-VASH Exit Worksheet (rev.10/01/2019) Page 2 of 5

4. Housing rented by Veteran with HUD-VASH voucher

5. Housing rented by Veteran with non-HUD-VASH housing subsidy

6. Permanent housing for formerly homeless persons (such as: CoC project or S+C)

7. Staying or living with family, permanent tenure

8. Staying or living with family, temporary tenure

9. Staying or living with friends, permanent tenure

10. Staying or living with friends, temporary tenure

11. GPD transitional housing

12. Non-VA transitional housing for homeless persons

13. VA MH RRTP

14. CWT/TR

15. Non-VA residential treatment program

16. Non-VA substance abuse treatment facility or detox center

17. Hospital or other residential non-psychiatric medical facility

18. Long-term care facility or nursing home

19. Psychiatric hospital or other psychiatric facility

20. Prison or jail

21. VA contracted residential treatment programs (HCHV Contract Residential Services)

22. Safe Haven (SH)

23. Hotel or motel paid for without emergency shelter voucher

24. Emergency shelter (ES), including hotel or motel paid for with emergency shelter voucher

25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station/airport or anywhere outside)

2. Public Housing Unit, such as housing fully funded or subsidized by HUD

8. What is the zip code of the location where the Veteran is residing at program exit (if unknown, use current location)?

9. Housing stability: How would you describe the Veteran’s housing situation at program exit?

1. Literally homeless 4. Stably housed

2. Imminent risk of losing housing 5. Don’t know

3. Unstably housed/at risk of losing housing

10. With whom will the Veteran be living at program exit?

0. No residence

1. Alone

2. With spouse/partner or children

3. With parents, with siblings, or with other family

4. With friends

5. With strangers

6. Don’t know

11. What is the Veteran’s arrangement for employment at program exit?

0. Disabled or retired

1. Unemployed

2. Actively seeking employment

3. Part-time or temporary employment

HUD-VASH Exit Worksheet (rev.10/01/2019) Page 3 of 5

4. Full-time employment

5. VA’s IT or CWT (VI) (NOTE: include CWT/TW only. IPS/SE and CBSE are considered employment.)

6. Other vocational training

7. Unpaid volunteer

8. Student

9. Don’t know

12. What is the Veteran’s arrangement for receipt of VA financial benefits (disability payments or pension) at the time of program exit?

0. Currently receiving VA benefits and will continue

1. Has pending application for VA financial benefits

2. Is planning to apply for VA financial benefits

3. Is neither receiving nor planning to apply for any VA financial benefits

4. Do not know Veteran’s status with respect to VA financial benefits

13. What is the Veteran’s arrangement for receipt of non-VA financial benefits (disability payments or other support) at the time of program exit?

0. Currently receiving non-VA benefits and will continue

1. Has pending application for non-VA financial benefits

2. Is planning to apply for non-VA financial benefits

3. Is neither receiving nor planning to apply for any non-VA financial benefits

4. Do not know Veteran’s status with respect to non-VA financial benefits

14. Did the Veteran receive any money in the 30 days prior to program exit? 0. No

99.Case manager omitted item

If 14=no or Case manager omitted item, skip to item 15 If yes, list amount in each category

Please round to whole dollar amounts and note comma placement (eg., $452.76 should be entered as $ _ _,453.00 )

a. Employment (include CWT/SE) $ , . 0 0

b. Compensation for service connected psychiatric condition $ , . 0 0

c. Compensation for other service connected condition $ , . 0 0

d. Non-service connected pension $ , . 0 0

e. Retirement income from Social Security $ , . 0 0

f. Pension from a former job $ , . 0 0

g. Supplemental Security Income (SSI) $ , . 0 0

h. Social Security Disability Income (SSDI) $ , . 0 0

i. Private disability insurance $ , . 0 0

j. Worker’s compensation $ , . 0 0

k. Unemployment insurance $ , . 0 0

l. Temporary Assistance for Needy Families (TANF) or similar local program $ , . 0 0

m. General Assistance (GA) or similar local program $ , . 0 0

n. Child support $ , . 0 0

o. Alimony or other spousal support $ , . 0 0

Total Amount [Total income calculated in HOMES].

15. Did the Veteran receive any of the following non-cash benefits in the 30 days prior to program exit?

99.Case manager omitted item

HUD-VASH Exit Worksheet (rev.10/01/2019) Page 4 of 5

If 15=no or Case Manager omitted item, skip to item 16 If yes, select each category

c. Temporary Rental Assistance 0. No 1. Yes

d. Homeless Prevention and Rapid Re-Housing Program (HPRP) Funds 0. No 1. Yes

e. Veteran Service Organizations 0. No 1. Yes

f. State Children’s Health Insurance Program or similar local program 0. No 1. Yes

g. Supplemental Nutrition Assistance Program (SNAP) or Food Stamps 0. No 1. Yes

h. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) 0. No 1. Yes

i. Temporary Assistance for Needy Families (TANF) or similar local program Child Care Services

0. No 1. Yes

j. Temporary Assistance for Needy Families (TANF) or similar local program Transportation Services

0. No 1. Yes

k. Other TANF-funded services 0. No 1. Yes

l. Bus, subway, train or cab voucher 0. No 1. Yes

n. Other (Specify) 0. No 1. Yes

IV. Follow-up Arrangements

Select the code that best describes clinical treatment arrangements made at program exit. Include arrangements for VA treatment only.

16. Alcohol problems

0. Not a problem area for this veteran

1. Problem area for this Veteran, but no treatment arrangements made

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

4. Veteran’s treatment has been arranged with both non-VA and VA provider

17. Drug problems

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

18. Mental health problems (other than drug or alcohol)

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

19. Medical problems

0. Not a problem area for this Veteran

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

20. Social and recreational deficits

0. Not a problem area for this Veteran

HUD-VASH Exit Worksheet (rev.10/01/2019) Page 5 of 5

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

Vocational skill deficits

2. Veteran’s treatment has been arranged with non-VA provider

3. Veteran’s treatment has been arranged with VA provider

Residential Treatment GPD Entry Worksheet (rev.10/1/19) Page 1 of 3

Residential Treatment GPD Entry Worksheet

Use this form for Veteran entry into the Grant and Per Diem Program (GPD).

Staff Login (first and last name) ..………

1. Date of screening decision for residential entry (mm/dd/yy): / /

2. Is the Veteran entering a residential treatment program? 0. No 1. Yes

If YES complete items 3a & 3b; if NO skip to item 4

3a. Date of program entry (mm/dd/yy): / /

3b. Residential program:

1…