Vet Haven South Admissions Referral Application Form

Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Eligibility

  • Be A Veteran eligible for Grant and Per Diem (GPD) Program through the VA.
  • Veteran must be committed to remaining drug and alcohol free.
  • Have either a reliable source of income or be a candidate to establish reliable income through employment and/or disability applications.
  • Not have any pending charges, arson or convictions for sexual offenses.
  • Be able to complete all Activities of Daily Living (ADL); manage own medications, mobility, dressing, showering, maintain room cleanliness.
  • Be willing/able to participate in assignment of chores.
  • Be medically and psychologically stable. (Evaluations with 14 days of application date)
  • Be willing to comply with all Veterans Haven rules and regulations.
  • Be willing to provide financial status and history to case manager monthly and pay rent as calculated.
  • Satisfactorily complete the interview process in person, via video conference (i.e. Skype/Zoom) or by phone.
  • Be registered with the Corporal Michael J. Crescenz VA Medical Center.
  • Sign Release of Information (ROI) between Veterans Haven, VA Medical, and any non-VA medical providers.
  • Have NO outstanding warrants. (If on Parole/Probation; must have written permission prior to admission)
Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Referral Information (if applicable) 

Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Veterans Information

Are you currently admitted to an inpatient/residential program?
Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Veterans Questionnaire

Have you ever had an eviction?
Does Veteran have health care insurance?
History of substance use disorder?
Any criminal charges/convictions?
Currently receiving medicated assisted treatment?
Mental health diagnosis?
Thoughts of suicide/suicide attempts?
Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Attachments

Downloadable Forms:

  1. Medical Certification Form
  2. Health Release Form

 

Select the items you have to upload:
Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Acceptance

  • Be A Veteran eligible for Grant and Per Diem (GPD) Program through the VA.
  • Veteran must be committed to remaining drug and alcohol free.
  • Have either a reliable source of income or be a candidate to establish reliable income through employment and/or disability applications.
  • Not have any pending charges, arson, or convictions for sexual offenses.
  • Be able to complete all Activities of Daily Living (ADL); manage own medications, mobility, dressing, showering, maintain room cleanliness.
  • Be willing/able to participate in assignment of chores.
  • Be medically and psychologically stable. (Evaluations with 14 days of application date)
  • Be willing to comply with all Veterans Haven rules and regulations.
  • Be willing to provide financial status and history to case manager monthly and pay rent as calculated.
  • Satisfactorily complete the interview process in person, via video conference (i.e. Skype/Zoom) or by phone.
  • Be registered with the Corporal Michael J. Crescenz VA Medical Center.
  • Sign Release of Information (ROI) between Veterans Haven, VA Medical, and any non-VA medical providers.
  • Have NO outstanding warrants. (If on Parole/Probation; must have written permission prior to admission)

Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN SOUTH

 

Policy

New Jersey Department of Military and Veterans Affairs Privacy Policy 
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