Intake Form Veteran Intake Form Please take the time and fill out as much information as possible, for things you wish not to disclose or don't understand, please leave blankThis information will be used to further assist Wisconsin Veterans Network in providing you assistance. All information will be secured and only shared with supporting agencies. If you have any questions, please feel free to call at 414-257-3624. Once complete, your VetsNet navigator will asses the information, and give you a call. First Name * Last Name * Middle Initial Date of Intake * Referred By211CRRCCVICVSODAVDOMDWDEventFacebookFriendHudvashHunger Task ForceLegionMHVIOtherRed CrossSelfTelemundo AdVAVFWWDVAWebsite Navigator who is assisting you (if unknown, leave blank) - select Navigator who is assisting you (if unknown, leave blank) - Quentin Amy Noah Debbie Sarah Lydia Tim Kirsten Joe Amy W. Kelsey Rachel Amy F Nate Gretchen Joseph Z Home or Mailing Address * City * State * Zip Code # County * Phone Number Email Are you enrolled in the VA? * Yes No DOB * Last 4 of SSN * Do you have a valid drivers license?Yes No Current Transportation Personal vehicle Bus Walk Friends or family Other GenderFemale Male Decline to answer Race - select Race - Native American or Alaskan Native Black or African American Caucasian-White Asian Native Hawaiian or Pacific Islander Hispanic/Latino Decline to answer Hispanic/Latino * Yes No Age Employed * Yes No Full or Part time - select Full or Part time - Full Time Part Time Last date of employment, if not employed? Employer Name Position Marital Status Divorced Life Partner Married Seperated Single Widowed Spouse's Name Has he/she ever served in military?Yes No Do you have minor children? * Yes No Gender and Ages of minor children Whom do the children reside with? - select Whom do the children reside with? - Veteran Spouse Both Other Guardian Branch of Service Army Air Force Marines Navy Coast Guard Space Force Reserves or National Guard Were you active duty?Yes No Years Served Combat AssignmentsYes No If yes, how long? (Total Months) Did you serve at least 90 days of active duty following 9/11/2001? Post 9/11 Veteran * Yes No Type of discharge * Dishonorable General Honorable Other Than Honorable Uncharacterized Under Honorable Unsure Bad Conduct Do you have access to your DD214? * Yes No Are you a member of any VSO?Yes No If yes, which onesAmerican Legion VFW DAV Other If other, please list Have you used these before?Center for Veteran's Issues (CVI)HudvashCounty Veteran's Service Office (CVSO)Suppportive Services for Veteran's Families (SSVF)Heat 4 HereosRent AssistanceMHVISalvation ArmyVAOtherVFW GrantLegion Grant Other Services used? How often have you visited VetsNet?1st Visit 2nd Visit 3rd Visit 4 or More Total amount of all income per month total Veteran Source of Income (Check all that apply)Employment Unemployment SSI SSDI VA Disibility Worker's Comp Retirement Pension No Income Other Non-Service or Service Connected Disability?Yes No Percentage of VA rating? (Just the number) Break down of Monthly Income Does Spouse WorkYes No Spouse Form of Income (Check all that apply)Employment Unemployment SSI SSDI VA Disibility Worker's Comp Retirement Pension No Income Other Spouse Total Income per Month Food Share BenefitsYes No Amount? Veterans Medical BenefitsYes No BadgerCareYes No Medicaid/MedicareYes No Hudvash/Section 8/Or other rent assistanceYes No Amount of Subsidy Rent or Mortgage amount Utilities for the month Phone bill for month Cable/Internet Car Payment/Car Insurance Child Support Other If Other, please list0 Total Monthly Expenses Amount VA ID Card Five Day Notice DD-214 Other File Have you ever had thoughts of self-harm or have previously attempted suicide? SSG Fox Qualifier 1 * Yes No Do you currently have suicidal thoughts or intentions? If so, please call the Veterans Crisis Line #988 SSG Fox Qualifier 2 * Yes No Release of Information * Yes No Summarize your needs * By submitting this form, you are agreeing to the following: I authorize the verification and release of the information provided on this form. I consent to the sharing of my information with VetsNet partners, community referral agencies, and other veteran service organizations for the purpose of assisting me with this situation. If you have any questions or concerns, please call us at 414-257-3624. Save
