D.5 REFERRAL FORM.pdf
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- Solicitation number
- 36C24226Q0118
About this file
This is an Emergency Housing Admission Referral Form (Attachment D.5) associated with RFQ 36C24226Q0118, designed to collect comprehensive information about veterans seeking emergency housing assistance.
The form captures detailed demographic and background information for veteran applicants, including name, date of birth, contact information, military service details (branch, years of service, discharge type, combat history), and identifying documents required (DD-214 or Statement of Military Service is mandatory). The form collects financial information including income sources, pending benefit applications, and financial obligations. A substantial portion of the form is dedicated to health and safety assessment, covering psychiatric status and history, current mental health treatment, suicide ideation/attempt history, substance use history and treatment, medical status, active medications, and history of abuse or trauma. The form also requests information on education, work history, legal history including arrests and assault history, and housing goals (independent living or transitional residence). Additional sections document the veteran's strengths, assets, barriers to achieving goals, and program expectations. The form requires all fields to be completed, with a note that falsifying information may result in disqualification from services. The referral should be forwarded to Scott Sussman at the specified contact information (fax: (908)604-5847, phone: (908)647-0180 X4425), accompanied by DD-214 or Statement of Military Service. A program staff section at the end documents receipt date, outreach timing, scheduled admission date, and requires signatures from both the person completing the form and the veteran applicant.
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Text version
Emergency Housing Admission Referral Please forward this referral along with
DD214 or Statement of Military Service to:
Scott Sussman
Fax (908)604- 5847
Phone (908)647-0180 X4425
Program Name:
Program Address:
Veteran Name: _____________________ Date: _____________
County Of Origin: ______________________ Hometown: _________________
Phone: ________________ Email: ______________________
D.O.B. _________ _____ Age: _______ Gender: __________________
Social Security #:____________________ Race: ________________
Insurance: _________________________
Income Sources and Amounts:
Any pending benefit application and date submitted (e.g., Service Connection, Social Security):
Additional benefit information: ______ ____________________
Financial obligations (child support, fines, etc. and amount owed):____________________________
ATTACHMENT D.5- REFERRAL FORM RFQ 36C24226Q0118
Marital Status: ______________________ Military Branch Served: ______________________
Years of Service: ____________________ History of Combat: _____________________
Type of discharge: ___________________
Reason for leaving service: ______________________________________________________________
Identifying Documents: DD-214/Statement of Service (required) Social Security Card Birth Certificate Award Letter Other:
Primary Language Spoken: ____________________
Valid Driver’s License and/or CDL: Yes No Do you have a vehicle: Yes No
Psychiatric Status and History (most recent diagnosis):
Current Mental Health Treatment Provider(s):
History of suicide ideation/attempt (date and method; did it result in hospitalization)
Do you currently have the desire and/or means to harm yourself?
History of thoughts to harm others or history of assault or violence:
Substance Use History (substances, route of use, date of last use):
Triggers of substance use
Treatment History and date last attended treatment (detox/rehab/outpatient):
Medical Status and History (including adaptive devices):
Allergies:
Active Medications and Prescribing MD:
History of Abuse/Trauma:
Education
High school: ____________________________ College: _____________
Additional School/Trainings/Skills :
Work History (last 2-3 jobs, dates of employment and type of work done):
Work/Education goal: ________________________________________________ ______
Housing goal (Independent living, transitional residence): __________________________
Strengths/Assets: ________________________________________________________
Barriers to achieving goal(s): __________________________________________________
What are your expectations from this program? _______________________________ ______
Legal History (dates outcomes/pending warrants):
History of arrest (including assault, domestic abuse, Megan’s Law)
Additional Comments: ________________________________________________________
Emergency Contact: _____
Relationship: ___________________ __ Phone: ___________________________
*Note: All fields are required. Falsifying information may disqualify you from eligibility of services.
Program Staff Use Only
Date Referral Received: _________________________________
Date/Time of staff outreach to VA: ________________________
Date/Time of Scheduled Admission: _______________________
Staff: ________________________________________________
Form Completed by: ___________________________________________ Date: _____________
Agency/relationship of person completing this form: _____________________________________
Address: ___________________________________ Phone: __________________________
Email: _____________________________________ Fax: ____________________________
Signature of person completing form __________________________________________________
Signature of Veteran _______________________________________________________________
File details come from the government source that posted it. Updated .