Fill - Free fillable VETERANS HAVEN NORTH State of New Jersey THE (State of New Jersey) PDF form

PHIL MURPHY

Governor

Commander-in-Chief

State of New Jersey

DEPARTMENT OF MILITARY AND VETERANS AFFAIRS

VETERAN’S HAVEN NORTH

“THE RALLY POINT”

200 SANATORIUM RD, SUITE 101

GLEN GARDNER, NEWJERSEY 08826

JEMAL J. BEALE

Brigadier General

The Adjutant General

APPLICATION FOR ADMISSION

FORWARD COMPLETED APPLICATION

WITH DD214 OR OTHER STATEMENT OF MILITARY SERVICE TO:

Attn: Jennifer Chrucky

Phone: 908-537-1999 Ext: 1980

Fax: 908-537-1990

Email: Jennifer.Chrucky@dmava.nj.gov

Personal Information:

1. Name: 2. SSN:

3. Age: DOB:

4. Ethnicity/Race: 5. Marital Status:

6. Have you been homeless before? Yes No

If yes, how many times:

Number of Dependents: Are your dependents homeless? Yes No

7. Have you ever been a resident at VHN? If so when?

8. List current residence/program address:

9. Please provide the name and phone number of the person assisting you with this application (if

applicable:

10. Date of Discharge from program/ Eviction:

11. List phone # where you can be reached:

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12. Please list your personal e-mail address, if applicable:

13. How long have you been homeless? :

Last Residence (not a Half-way House/ Program):

14. Home Town/ State/County:

15. Branch of Service: Years Served:

Combat? /Where? ______________________________________________________________________________

Type of Discharge: _____________________________________________________________________________

Overseas Duty? /Where:

MOS/Job Title:

Reason for leaving the Military:

16. Have you attached your DD214 or a Statement of Service? Yes No

17. Do you have health care insurance? Yes No

If yes, please detail the provider:

VA Healthcare Medicaid Medicare Private Insurance

Other:

18. If you aren’t currently receiving VA Healthcare benefits, are you eligible for them?

Yes No

II.

Substance Abuse Information:

1. Do you have a history of substance abuse/dependence? Yes No

If yes, complete this section.

2. Drug(s) of Choice (including tobacco):

Period(s) of Use:

3. Last Use and Triggers:

4. List the types of substance abuse treatment program(s) you haveattended:

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Do you currently have the desire and means to harm yourself or others?

Yes

III.

Mental Health:

Do you have a history of mental health treatment? Yes No

If yes, complete this section.

1. List any/all psychiatric diagnosis (PTSD?):

2. List any treatment you are currently receiving (therapy/outpatient/ medications, etc.):

3. List any treatment you are currently receiving (therapy/outpatient/ medications, etc.):

4. Have you experienced any traumatic event(s) you are willing to disclose at this time?

5. Have you ever had thoughts of suicide? Yes No

Have you ever hurt yourself intentionally?

Yes

If yes, please explain:

6. Have you ever had thoughts of harming others? Yes No

Have you ever attempted to severely injure another? Yes No

If yes, please explain:

7. No

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IV.

Medical Issues

1. List any/all medical diagnosis(es)/ physical problem(s):

2. Have you been tested for Hepatitis:

TB:

HIV:

Results:

3. Are you receiving or do you need therapy for the above listed diagnosis: Yes No

4. List any/all medications you are currently taking:

5. Please list any known allergies:

Educational/Vocational History:

1. When did you last work:

What kind of job was it:

2. What vocational training have you had (include dates):

3. What is your highest level of education:

4. What would you want to do educationally and/or vocationally with your life:

a. Are there any medical or other issues which would preclude you from

this: If yes, please list:

VI.

Financial/ Legal Issues:

1. Do you have income (e.g. VA Disability, Employment, Unemployment, Social Security,

etc.): If yes, please list amount/source:

2. Do you have an application pending for Social Security Disability or Non-Service

connected Pension:

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3. Do you have any financial obligations? (e.g. child support, student loans, fines, IRS,

credit cards):

4. List any/all legal problems (past, present, and/or pending), include dates and outcomes,

not to be limited to and including the following: arrested and convicted for a crime(s),

incarcerations, court appointed restitutions, been on or are on probation and/or parole,

any/all outstanding warrants:

5. Have you ever been arrested for and convicted of assault or domestic abuse:

If yes, explain (include dates and outcome(s):

6. Have you ever been arrested for and/or convicted under Megan’s law or a similarlaw

against child molestation: If yes, explain (include dates and outcome(s):

7. Do you have a valid Driver’s License: What state: Is it valid:

Do you have a CDL License: Issuing state: Class:

Do you have a vehicle: Plans to bring one to Veteran’s Haven:

VI. Applicant Narrative:

1. List some of your strong points:

List some of your weak points:

2. What do you see yourself doing in the next two years:

4. What is the biggest obstacle to achieving your goals:

4. Why do you want to come to Veteran’s Haven:

5. What do you expect from this program:

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VII. Applicant Statement:

1. 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).

2. 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 myadmission.

3. 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 tofollow.

4. 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.

5. 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.

6. I un

derstand that I will need to sign release of information forms for healthcare providers,

parole officers, etc. for coordination of my treatment plan.

7. 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.

8. 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.

(Applicant Signature) (Date)

*Please note: In addition to the Application for Admission, anyone pursuing residency in the Veteran’s

Haven North Transitional Housing Program must also submit the following “Medical Certification for

Supervised Residential Housing” form. This can be completed by any Physician of Advanced Practice

Nurse who has recently evaluated and/or cared for the applicant. The forms should then be submitted to

Veteran’s Haven North, attention:

Jennifer Chrucky

200 Sanatorium Road, Suite 101

Glen Gardner, NJ 08826

Fax: 908-537-1990

Phone: 908-537-1980

click to sign

signature

click to edit

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VA Release of Information Instructions

The veteran must complete, in his/her own printed hand-writing, the following sections:

First Page:

• name

• s

ocial security number

• date of birth

Second Page:

• name

• s

ocial security number

• date of birth

• date of signature

The veteran must hand-sign the following:

Second Page:

• signature

Please note:

• no other sections need to be completed, electronically or by-hand, as it is pre-filled

with all pertinent and required information

• no pre-checked items should be changed, electronically or by-hand, as it is pre-filled

with all pertinent and required information

Questions? Contact GPD Liaison:

Marilynn Mastrella 908.647.0180 x6985

Text

REQUEST FOR AND AUTHORIZATION TO

RELEASE HEALTH INFORMATION

PRIVACY ACT AND PAPER WORK REDUCTION ACT INFORMATION: The Paperwork Reduction Act of 1995 requires us to notify

you that this information collection is in accordance with the clearance requirements of section 3507 of the Act. We may not conduct or sponsor,

and you are not required to respond to, a collection of information unless is displays a valid OMB number. We anticipate that the time expended

by all individuals who must complete this form will average 2 minutes. This includes the time it will take to read the instructions, gather the

necessary facts and fill out this form. The execution of this form does not authorize the release of information other than that specifically

described below.

The information requested on this form is solicited under Title 38 U.S.C. The form authorizes release of information in accordance with the

Health Insurance Portability and Accountability Act, 45 CFR Parts 160 and 164; 5 U.S.C. 552a; and 38 U.S.C. 5701 and 7332 that you specify.

Your disclosure of the information requested on this form is voluntary. However, if the information including the last four of your Social Security

Number (SSN) and Date of Birth (used to locate records for release) is not furnished completely and accurately, VA will be unable to comply

with the request. The Veterans Health Administration may not condition treatment, payment, enrollment or eligibility on signing the

authorization. VA may disclose the information that you put on the form as permitted by law. VA may make a “routine use” disclosure of the

information as outlined in the Privacy Act system of records notices identified as 24VA10P2 “Patient Medical Record – VA”, 08VA05

“Employee Medical File System Records (Title 38)-VA” and in accordance with the Notice of Privacy Practices. VA may also use this

information to identify veterans and person claiming or receiving VA benefits and their records, and for other purposes authorized or required by

law.

TO: DEPARTMENT OF VETERANS AFFAIRS (Name and Address of VA Health Care Facility)

VA New Jersey Health Care System

385 Tremont Avenue

East Orange, NJ 07018

LAST NAME- FIRST NAME- MIDDLE INITIAL

LAST 4 SSN

DATE OF BIRTH

NAME AND ADDRESS OF ORGANIZATION, INDIVIDUAL, OR TITLE OF INDIVIDUAL TO WHOM INFORMATION IS TO BE RELEASED

PURPOSE(S) OR NEED: Information is to be used by the individual for:

TREATMENT BENEFITS LEGAL EMPLOYMENT

OTHER (Please specify)

INFORMATION REQUESTED: Check applicable box(es) and state the extent or nature of information to be provided:

HEALTH SUMMARY (Prior 2 Years)

INPATIENT DISCHARGE SUMMARY (Dates):

PROGRESS NOTES:

SPECIFIC CLINICS (Name & Date Range):

SPECIFIC PROVIDERS (Name & Date Range):

DATE RANGE:

OPERATIVE/CLINICAL PROCEDURES (Name & Date):

LAB RESULTS:

SPECIFIC TESTS (Name & Date):

DATE RANGE:

RADIOLOGY REPORTS (Name & Date):

LIST OF ACTIVE MEDICATIONS:

FLU VACCINATION (Dose, Lot Number, Date & Location):

OTHER (Describe):

VA FORM

SEP 2018

10-5345

Page 1 of 2

Veteran’s Haven North

200 Sanatorium Road

Glen Gardner, NJ 08826

referral, screening, assessment;

ongoing case management services

medical records and verification of services/eligibility (as available) required for the provision of case management services

LAST NAME- FIRST NAME- MIDDLE INITIAL

LAST 4 SSN

DATE OF BIRTH

SENSITIVE DIAGNOSES: REVIEW AND, IF APPROPRIATE, COMPLETE WHEN RELEASE IS FOR ANY PURPOSE

OTHER THAN TREATMENT.

I request and authorize Department of Veterans Affairs to release the information pertaining to the condition(s) below for the non-treatment

purpose(s) listed in this authorization.

DRUG ABUSE ALCOHOLISM OR ALCOHOL ABUSE SICKLE CELL ANEMIA

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

I understand that information on these sensitive diagnoses may be released for treatment purposes without me checking the above boxes, and will be

released even if the boxes are unchecked unless I indicate by checking the box below that I do not want this information released for this specific

disclosure.

I do not want sensitive diagnoses released for treatment purposes under this specific authorization. I realize this does not impact

other future requests unrelated to this authorization.

AUTHORIZATION: I certify that this request has been made freely, voluntarily and without coercion and that the information given above is

accurate and complete to the best of my knowledge. I understand that I will receive a copy of this form after I sign it. I may revoke this

authorization in writing, at any time except to the extent that action has already been taken to comply with it. Written revocation is effective upon

receipt by the Release of Information Unit at the facility housing records. Any disclosure of information carries with it the potential for

unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.

I understand that the VA health care provider’s opinions and statements are not official VA decisions regarding whether I will receive other VA

benefits or, if I receive VA benefits, their amount. They may, however, be considered with other evidence when these decisions are made at a VA

Regional Office that specializes in benefit decisions.

EXPIRATION: Without my express revocation, the authorization will automatically expire.

AFTER ONE-TIME DISCLOSURE, IF ALL NEEDS ARE SATISFIED

ON (enter a future date other than date signed by patient)

UNDER THE FOLLOWING CONDITION(S):

PATIENT SIGNATURE (Sign in ink)

DATE (mm/dd/yyyy)

LEGAL REPRESENTATIVE SIGNATURE (if applicable) (Sign in ink)

DATE (mm/dd/yyyy)

PRINT NAME OF LEGAL REPRESENTATIVE

RELATIONSHIP TO PATIENT

FOR VA USE ONLY

TYPE AND EXTENT OF MATERIAL RELEASED

DATE RELEASED

RELEASED BY:

VA FORM 10-5345, SEP 2018

Page 2 of 2

30 days following discharge from Veteran’s Haven North (to accommodate any follow-up).

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