ATTACHMENT J - RESIDENTIAL EXIT FORM WORKSHEET.doc
DOC document 185 KB Posted
- Attached to
- G004--EMERGENCY RESIDENTIAL BEDS - SPA 5-LDSH
- Solicitation number
- 36C26225R0090
About this file
This document is a Residential Treatment Exit Form Worksheet used by VA staff to document Veterans' exits from residential treatment programs. The comprehensive form captures detailed information about a Veteran's status at program exit, including housing arrangements, employment status, financial benefits, income sources, and follow-up treatment arrangements across multiple categories such as alcohol problems, drug problems, mental health issues, medical problems, social skills, and vocational capabilities.
The form is associated with a VA solicitation (36C26225R0090) for Emergency Residential Beds in Service Planning Area 5 (SPA 5-LDSH), issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 22, located in Long Beach, California. The solicitation is for Product Service Code G004 and NAICS Code 624229, with a response deadline of September 25, 2025, at 10 AM Pacific Time. The procurement does not involve Recovery Act funds and does not appear to have a specific set-aside designation.
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Other files
| File | Type | Posted |
|---|---|---|
| ATTACHMENT I - QUALITY ASSURANCE.docx | DOCX document | |
| D.3 REFERENCE CONTRACT WORKSHEET.docx | DOCX document | |
| 36C26225R0090_2.docx | DOCX document | |
| ATTACHMENT H - INCIDENT REPORT.docx | DOCX document | |
| ATTACHMENT D - EXTENSION REQUEST - BLANK.docx | DOCX document | |
| ATTACHMENT K - SQUARES QUICK REFERENCES.pdf | ||
| ATTACHMENT G- HOMES RESIDENTIAL TREATMENT REFERRAL WORKSHEET.docx | DOCX document | |
| ATTACHMENT F - ADMISSION DENIAL REFERRAL TRACKER.xlsx | XLSX spreadsheet | |
| ATTACHMENT C - HEALTHCARE FOR HOMELESS VETERANS INCIDENT REPORT.docx | DOCX document | |
| ATTACHMENT B - CONTRACT RULES OF BEHAVIOR AGREEMENT.pdf | ||
| S02 - 36C26225R0090.docx | DOCX document | |
| ATTACHMENT E - SQUARES.pdf | ||
| ATTACHMENT A - ADA ACCESSIBILITY CHECKLIST FOR EMERGENCY SHELTERS.pdf |
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Text version
Residential Treatment Exit Form Worksheet
Use this form to document exit of Veterans from a Grant and Per Diem program (GPD), HCHV Contract Residential Treatment Program, and HCHV Low Demand Safe Haven.
Staff member completing this form (first and last name) ..………
| VA Site (3-digit VAMC code plus 2-digit suffix, if any) …………. |
| __6__ __9__ _1___ ____ ____ |
| Date this form completed (mm/dd/yy)……………..…...……...… |
| ____ ____ / ____ ____ / ____ ____ |
I. Veteran Information
Veteran’s name (last name, first initial)……………….……………
| Social Security number………………...……….……………..….. |
| ____ ____ ____ - ____ ____ - ____ ____ ____ ____ |
| Date of birth (mm/dd/yy)…………………………………………… |
| ____ ____ / ____ ____ / ____ ____ |
II. Residential Treatment Stay
Program Type ………………………….……………….……………
Project Code ………..………………….……………….……………
Program Name …..…………………….……………….……………
| 1. |
| Period covered by this report |
(Code dates: mm/dd/yy) Entry date:
Exit date:
1a. Billable Days (LOS) and Cost of Care (to be completed for GPD, HCHV, DCHV)
| Unpaid days: |
| __ __ __ |
| Billable days (LOS): |
| __ __ __ __ __ |
| Cost of treatment (round to nearest dollar): |
| $__ __ , __ __ __ |
III. Status at Program Exit
| 2. |
| The Veteran ended residential treatment because: |
FORMCHECKBOX
1. Successful completion of the program
FORMCHECKBOX
2. Successfully completed some components of the program
FORMCHECKBOX
3. Veteran was asked to leave because of violation of program rules or failure to comply with program requirements
FORMCHECKBOX
4. Veteran required a more intensive level of care than offered at this program
FORMCHECKBOX
5. Veteran was transferred to another residential program for administrative reasons
FORMCHECKBOX
6. *Veteran left the program by his/her own decision, without consulting staff
FORMCHECKBOX
7. Veteran was incarcerated
FORMCHECKBOX
8. Veteran is deceased
*For AWOL Veterans, program staff must attempt to locate the veteran prior to forwarding & officially discharging them.
If item 2 = 8 (Veteran is deceased), do not complete the remainder of the form
| 2a. |
| If the Veteran ended residential treatment because of a rule violation, what was the most important reason? |
FORMCHECKBOX
1. Threatened/actual violence to self or others (exclusion)
FORMCHECKBOX
2. Use of alcohol or drugs
FORMCHECKBOX
3. Curfew violation
FORMCHECKBOX
4. Other (please specify) __________________________________________
| 3. |
| What is the Veteran’s housing arrangement at program exit (location where the Veteran was sleeping on the night of program exit) ? |
FORMCHECKBOX
1. Housing owned by Veteran, no ongoing housing subsidy
FORMCHECKBOX
2. Housing owned by Veteran, with ongoing housing subsidy
FORMCHECKBOX
3. Housing rented by Veteran, no ongoing housing subsidy
FORMCHECKBOX
4. Housing rented by Veteran with HUD-VASH voucher
FORMCHECKBOX
5. Housing rented by Veteran with non-HUD-VASH housing subsidy
FORMCHECKBOX
6. Permanent housing for formerly homeless persons (such as SHP, S+C, or SRO MOD Rehab)
FORMCHECKBOX
7. Staying or living with family, permanent tenure
FORMCHECKBOX
8. Staying or living with family, temporary tenure
FORMCHECKBOX
9. Staying or living with friends, permanent tenure
FORMCHECKBOX
10. Staying or living with friends, temporary tenure
FORMCHECKBOX
11. GPD transitional housing
FORMCHECKBOX
12. Non-VA transitional housing for homeless persons
FORMCHECKBOX
13. VA MH RRTP
FORMCHECKBOX
14. CWT/TR
FORMCHECKBOX
15. Non-VA residential treatment program
FORMCHECKBOX
16. Non-VA residential substance abuse treatment facility or detox center
FORMCHECKBOX
17. Hospital or other residential non-psychiatric medical facility
FORMCHECKBOX
18. Long-term care facility or nursing home
FORMCHECKBOX
19. Psychiatric hospital or other psychiatric facility
FORMCHECKBOX
20. Prison or jail
FORMCHECKBOX
21. VA contracted residential treatment programs (HCHV Contract Residential Services)
FORMCHECKBOX
22. Safe Haven (SH
FORMCHECKBOX
23. Hotel or motel paid for without emergency shelter voucher
FORMCHECKBOX
24. Emergency Shelter (ES), including hotel or motel paid for with emergency shelter voucher
FORMCHECKBOX
25. Place not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station or anywhere outside)
FORMCHECKBOX
26. Don’t know
Specify subsidy type:
FORMCHECKBOX
1. Mainstream (non-HUD-VASH) Housing Choice Voucher
FORMCHECKBOX
2. Public Housing Unit, such as housing fully funded or subsidized by HUD
FORMCHECKBOX
3. SSVF Rapid Rehousing (RRH) or equivalent RRH subsidy
FORMCHECKBOX
4. Other subsidized housing, including locally-funded subsidized housing
| 4. |
| What is the zip code of that location? Code N in 1st space if unknown. |
| ____ ____ ____ ____ ____ |
Full Address:
Phone Number:
4a. In which CoC will the Veteran be residing at the time of program exit (if unknown, use current location)?
Los Angeles City & County CoC
FORMCHECKBOX
Santa Maria/Santa Barbara County CoC
FORMCHECKBOX
Bakersfield/Kern County CoC
FORMCHECKBOX
Pasadena CoC
FORMCHECKBOX
Oxnard, San Buenaventura/Ventura County CoC
FORMCHECKBOX
Glendale CoC
FORMCHECKBOX
San Luis Obispo County CoC
FORMCHECKBOX
Veteran will be residing in a CoC outside the VAMC catchment area.
| 5. |
| Housing stability: How would you describe the Veteran’s housing situation at program exit? |
FORMCHECKBOX
1. Literally homeless
FORMCHECKBOX
2. Imminent risk of losing housing
FORMCHECKBOX
3. Unstably housed/at risk of losing housing
FORMCHECKBOX
4. Stably housed
FORMCHECKBOX
5. Don’t know
| 6. |
| With whom will the Veteran be living at program exit? |
FORMCHECKBOX
0. No residence
FORMCHECKBOX
1. Alone
FORMCHECKBOX
2. With spouse/partner or children
FORMCHECKBOX
3. With parents, with siblings, or with other family
FORMCHECKBOX
4. With friends
FORMCHECKBOX
5. With strangers
FORMCHECKBOX
6. Don’t know
| 7. |
| What is the Veteran’s arrangement for employment at program exit? |
FORMCHECKBOX
0. Disabled or retired
FORMCHECKBOX
1. Unemployed
FORMCHECKBOX
2. Actively seeking employment
FORMCHECKBOX
3. Part-time or temporary employment
FORMCHECKBOX
4. Full-time employment
FORMCHECKBOX
5. VA’s IT or CWT (VI) (NOTE: include CWT/TW only. IPS/SE and CBSE are considered employment.)
FORMCHECKBOX
6. Other vocational training
FORMCHECKBOX
7. Unpaid volunteer
FORMCHECKBOX
8. Student
FORMCHECKBOX
9. Don’t know
8.
What is the Veteran’s arrangement for receipt of VA financial benefits (disability payments or pension) at the time of program exit?
FORMCHECKBOX
0. Currently receiving VA benefits and will continue
FORMCHECKBOX
1. Has pending application for VA financial benefits
FORMCHECKBOX
2. Is planning to apply for VA financial benefits
FORMCHECKBOX
3. Is neither receiving nor planning to apply for any VA financial benefits
FORMCHECKBOX
4. Do not know Veteran’s status with respect to VA financial benefits
| 9. |
| What is the Veteran’s arrangement for receipt of non-VA financial benefits (disability payments or other support) at the time of program exit? |
FORMCHECKBOX
0. Currently receiving non-VA benefits and will continue
FORMCHECKBOX
1. Has pending application for non-VA financial benefits
FORMCHECKBOX
2. Is planning to apply for non-VA financial benefits
FORMCHECKBOX
3. Is neither receiving nor planning to apply for any non-VA financial benefits
FORMCHECKBOX
4. Do not know Veteran’s status with respect to non-VA financial benefits
| 10. |
| Did the Veteran receive any money in the 30 days prior to program exit? |
If 10 = no or Case manager omitted item, skip to item 11
If 10 = yes, list the average monthly amount in each category
FORMCHECKBOX
0= No
FORMCHECKBOX
1=Yes
99= Case manager omitted item
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 |
| p. All other sources (do not include food stamps) |
| $ ___ ___ , ___ ___ ___ . 0 0 |
| Total Amount |
| [Total income calculated in HOMES]. |
| 11. |
| Did the Veteran receive any non-cash benefits in the 30 days prior to program exit? |
If 11 = no or Case Manager omitted item, skip to item 12
If 11 = yes, indicate type(s) of benefits received
FORMCHECKBOX
0= No
FORMCHECKBOX
1=Yes
FORMCHECKBOX
99= Case manager omitted item
| a. Medicaid health insurance program or similar local program |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| b. Medicare health insurance program or similar local program |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| c. Temporary Rental Assistance |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| d. Homeless Prevention and Rapid Re-housing Program (HPRP) Funds |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| e. Veteran Service Organizations |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| f. State Children’s Health Insurance Program or similar local program |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| g. Supplemental Nutrition Assistance Program (SNAP) or Food Stamps |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| h. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| i. Temporary Assistance for Needy Families (TANF) or similar local program Child Care Services |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| j. Temporary Assistance for Needy Families (TANF) or similar local program Transportation Services |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| k. Other TANF-funded services |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| l. Bus, subway, train or cab voucher |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
| m. Other |
| FORMCHECKBOX |
0= No FORMCHECKBOX 1=Yes
SNAP:
Strengths:
Needs:
Abilities:
Preferences:
Transitional Plan:
1. List of referrals for on-going unresolved issues.
2. List of providers with whom the Veteran is involved (VA and community).
3. Progress & Community Support towards recovery:
IV. Follow-up Arrangements
Select the code that best describes clinical treatment arrangements made at program exit.
| 12. |
| Alcohol problems |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
| 13. |
| Drug problems |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
| 14. |
| Mental health problems (other than drug or alcohol) |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
| 15. |
| Medical problems |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
| 16. |
| Social and recreational deficits |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
| 17. |
| Vocational skill deficits |
FORMCHECKBOX
0. Not a problem area for this veteran
FORMCHECKBOX
1. Problem area for this Veteran, but no treatment arranged
FORMCHECKBOX
2. Veteran’s treatment has been arranged with non-VA provider
FORMCHECKBOX
3. Veteran’s treatment has been arranged with VA provider
FORMCHECKBOX
4. Veteran’s treatment has been arranged with both non-VA and VA provider
File details come from the government source that posted it. Updated .