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VETERAN INTAKE FORM
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Date of Entry
Date of Discharge
Check off all applicable categories below
Service Connected Disability or pending claim with V.A.
Vietnam Era, period beginning February 28, 1961 and ending May 7, 1975
Homeless or at risk of homelessness.
Fleeing or attempting to flee hostile housing situation.
Between the ages of 18 and 24.
Exited the military within the previous 12 months, and have been unemployed for 27 + weeks (cumulative).
Previously incarcerated and require assistance overcoming barriers resulting from arrest or conviction.
Lack a High School Diploma or GED (HiSet)
Receiving MA CH 115 benefits
Low income based on chart below:
Transitioning Service Member.
Spouse of a military member or former military member who, a) died from service connected injuries, b) KIA/MIA, c) 100% disabled
None of the above apply to my current situation
Would like to speak with a Veterans Representative
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