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 AdVAVFWWDVAWebsiteNavigator 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 NumberEmail 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 answerRace - 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 NoAge Employed * Yes NoFull or Part time - select Full or Part time - Full Time Part Time Last date of employment, if not employed?Employer NamePositionMarital Status Divorced Life Partner Married Seperated Single Widowed Spouse's NameHas he/she ever served in military?Yes No Do you have minor children? * Yes NoGender and Ages of minor childrenWhom 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 ServedCombat 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 NoAre you a member of any VSO?Yes No If yes, which onesAmerican Legion VFW DAV OtherIf other, please listHave 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 GrantOther Services used?How often have you visited VetsNet?1st Visit 2nd Visit 3rd Visit 4 or MoreTotal amount of all income per month totalVeteran Source of Income (Check all that apply)Employment Unemployment SSI SSDI VA Disibility Worker's Comp Retirement Pension No Income OtherNon-Service or Service Connected Disability?Yes No Percentage of VA rating? (Just the number)Break down of Monthly IncomeDoes Spouse WorkYes No Spouse Form of Income (Check all that apply)Employment Unemployment SSI SSDI VA Disibility Worker's Comp Retirement Pension No Income OtherSpouse Total Income per MonthFood Share BenefitsYes No Amount?Veterans Medical BenefitsYes No BadgerCareYes No Medicaid/MedicareYes No Hudvash/Section 8/Or other rent assistanceYes No Amount of SubsidyRent or Mortgage amountUtilities for the monthPhone bill for monthCable/InternetCar Payment/Car InsuranceChild SupportOtherIf Other, please list0Total Monthly Expenses AmountVA ID CardFive Day NoticeDD-214Other FileHave you ever had thoughts of self-harm or have previously attempted suicide? SSG Fox Qualifier 1 * Yes NoDo 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
