Vet Haven North Admissions Referral Application Form

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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Eligibility

  • Veteran must be homeless.
  • Individual must be a veteran under USDVA guidelines.
  • Veteran must be registered with the VA.
  • Applicant must be drug and alcohol free at time of admission.
Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Personal Information

Gender
Have you been homeless before?
Are your dependents homeless:
Are you currently on a mortgage, deed or lease for any residential property:
Do you have healthcare insurance:
If yes, please detail the provider:
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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Military Information

Do you have a copy of your DD214 or a Statement of Service:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Substance Abuse Information

Do you have a history of substance abuse / dependence:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Mental Health

Do you have a history of mental health treatment:
Have you ever had thoughts of suicide:
Have you ever hurt yourself intentionally:
Have you ever had thoughts of harming others:
Have you ever attempted to severely injure another:
Do you currently have the desire and means to harm yourself or others:
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ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Medical Issues

Have you been tested for Hepatitis:
Have you been tested for TB:
Have you been tested for HIV:
Are you receiving or do you need therapy for the above listed diagnosis:
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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Educational / Vocational History

Are there any medical or other issues which would preclude you from this:
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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Financial / Legal Issues

Do you have income (e.g. VA Disability, Employment, Unemployment, Social Security, etc.):
Have you ever been arrested for and / or convicted under Megan’s law or a similar lawagainst child molestation:
Do you have a valid Driver’s License:
Is it valid:
Do you have a CDL License:
Do you have a vehicle:
Plans to bring one to Veteran’s Haven:
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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Applicant Narrative

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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Attachments

Downloadable Forms:

  1. Medical Certification Form
  2. Health Release Form

 

Select the items you have to upload:
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ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Applicant Statement:

  • I understand that, as part of the application process, I must be agreeable to provide military and medical documentation, including, but not limited to: DD214, blood work (including pregnancy test for women), urine drug screen, and tuberculosis screening (PPD).

  • I understand I must provide Veteran’s Haven North with my contact information and communicate any changes to that information, immediately, in order to facilitate my admission.

  • I understand that if I am accepted to Veteran’s Haven North, I would be provided with copies of the rules/regulations and policy and procedures, which I will be expected to follow.

  • I understand that if I am accepted to Veteran’s Haven North, I would work with the staff to establish and adhere to a treatment plan.

  • I understand that, as a resident at Veteran’s Haven North, I would be assigned collective duty assignments / chores related to the function and daily operation of the home.

  • I understand that I will need to sign release of information forms for healthcare providers, parole officers, etc. for coordination of my treatment plan.

  • I understand that, if I fail to answer application questions honestly and accurately, my admission and/or residency at Veteran’s Haven North may be affected.

  • I understand that, should I be accepted for residency at Veteran’s Haven North, my failure to meet the aforementioned expectations may also affect my residency there.

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Image OFFICIAL SITE OF THE STATE OF NEW JERSEY

 

ImageDepartment of Military and Veterans Affairs

 

 

ADMISSIONS REFERRAL APPLICATION FORM FOR VETERANS HAVEN NORTH

 

Policy

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