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Name*

First Last

Email*

Service

In which military service war era did you serve?

(Example: OEF, OIF, Persian Gulf, Vietnam, Korean, etc)

Have you served in the following locations?

Service Location

If you selected 'Other' above.

Were you ever engaged in hostile or friendly fire?

Yes
No

If yes, what kind?

Hostile
Friendly

Dates of Service:

Branch of Service:

Total Months on Active Duty:

Are you currently receiving any services through the VA?

Yes
No

Referred by (Agency/Individual and Phone Number)

Date of Birth*

Sex*

Male
Female

Race*

(Needed for HMIS)

Veteran's Current Telephone Number*

County/City*

Example: Davidson or Nashville

Have you ever received help from SSVF in the past?

Yes
No

Do you have a copy of your DD 214 Form?*

Yes (if yes, you will be asked to provide a copy)
No

Housing Information

Are you currently homeless?*

Yes
No

If yes, how long?

If veteran is currently residing in permanent housing and eligible for SSVF Services, do you have an eviction notice?

If yes is marked SSVF Staff need to complete Eligibility Screening Disposition Form, if yes, provide copy of eviction notice.

Yes
No

What is veteran’s current address?

Street Address Address Line 2 City State ZIP Code

How many times have you been displaced or evicted from your home in the past 4 years?

Please describe your current living situation:

Is there anything in your background that is going to make it difficult to house you?

Convicted Felon
Bad Criminal History
Bad Credit
History of Evictions
Other

If other, please describe.

Do you have a Utility Cut Off Notice?

Yes
No

How many months behind are you on utilities?

(SSVF can only assist for a maximum of 2 months.)

Income

Do you have an income?

Yes
No

Source of Income

Select all that apply. To make multiple selections, hold down the Ctrl key while clicking on each option.

Monthly Income

(total from all sources)

Are you seeking other means of income?

Yes
No

If yes, please explain.

Additional Information

Do you or any member of your household have any disability that should be given special consideration while locating or placing in permanent housing?*

Yes
No

Are you currently enrolled in school either full-time or part-time through the G.I. Bill?*

Yes
No

How much is your monthly stipend?*

Household:

Please list all members of the household and include Age, Sex, DOB, and Relationship to the Veteran:

Additional Information:

SSVF Screening Tool

Service

Housing Information

Income

Additional Information