Veteran’s Haven North: Treatment Team: Application for Admission Form: update 6/15/2020
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:
200 Sanatorium Road, Suite 101
Glen Gardner, NJ 08826
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