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Veterans MUST Read Before Interview

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Supporting Veteran Families
“Beyond the Battlefield”
Since 2005
Veterans MUST Read Before Interview
You are being assessed for your enrollment into the Emergency and/or Transitional Housing
Program offered by the Veterans Integration Centers (VIC). All questions need to be completed
in order for our team to determine eligibility and what the best course of action is to help you in
your road to recovery. NO one question will make you Ineligible for services, so please be truthful
and complete in your answers. As part of the assessment process, you are being informed of the
basic requirements IF enrolled in one of our programs:
1. Veterans are subject to a 7-day probationary period in which the VIC can elect to terminate
services based on your commitment, participation and adherence to all VIC policies & procedures
2. Veterans, and their family members, are NOT allowed to use illegal drugs or alcohol at any
time and will be tested randomly
3. Veterans cannot refuse random or mandatory drug or alcohol testing by VIC employees
4. Veterans may have any discharge type EXCEPT Dishonorable
5. Veterans are required to conduct monthly volunteer or community services hours as part of
enrollment in our Transitional Housing program
6. For Veterans who have a history of substance use (including alcohol), you are required to
attend drug or alcohol outpatient treatment or support groups either at the VA, Healthcare for the
Homeless, or a community mental health or substance use support program
7. If deemed ELIGIBLE to work, the Veteran will be required to actively search for employment
beginning after completion of the first 30-days of enrollment
8. Veterans without family are required to live with roommates in our Transitional Housing facility
and adhere to all rules and policies in place
9. Veterans, and family members, consent to background checks as part of enrollment eligibility
into VIC programs, BUT, criminal history does not necessarily disqualify you
10. Veterans may be required to provide a Participation Fee based on their unique situation
monthly to the VIC, as directed by their case manager
11. All participants are required to authorize the VIC to enter your data into the Homeless
Management Information System (HMIS), a database used to collect client-level data and data
on the provision of housing and services to homeless individuals and families and persons at risk
of homelessness
Privacy Statement: The VIC declares that all information collected from the Veteran or their
family member(s) are considered CONFIDENTIAL. The VIC will not share information on you or
your case unless you sign a Release of Information, or other document as required by state or
federal law.
Please fax or email completed application to: 505-332-8092 or info@nmvic.org
1
Application for Enrollment
Emergency or Transitional Housing
GENERAL INFORMATION
DateSubmitted_______________________ EmailofApplicant________________________________
VeteranName_____________________________________________________________________________
LAST FIRSTMI
Haveyoueverusedorbeenknownbyanyothername?(Ifyes,pleaselist)___________________________
SSNumber________________________________CellPhone#________________________________
DateofBirth________________________________ Gender Male Female
Transgender Other
Wheredidyoustaylastnight?(ex.Shelter,car,streets,friend’shouse,jail)____________________________
Howlonghaveyoubeenstayingthere?________________________________
Howmanytimeshaveyoubeenhomelessinthelast3years?________________________________
Abouthowmanymonthstotal?________________________________
Tell us about your last PERMANENT residence
City________________________________State_________________________ZipCode______________
From________________________________To________________________________
Whydidyouleavethere?________________________________________________________________
Military Service Information
HaveyoueverservedintheMilitary? YES NO Branch Army Navy USAF
USMC CoastGuard
HaveaDD214orNGB22YESNO Status ActiveReserve NationalGuard
DatesofService From________________________________
*Ifmultipleperiodsorbranchespleaselistmost
recentandletVICemployeeknow
To________________________________
DischargeType HonorableGeneralOtherThanHonorableBadConduct

*EntryLevelorDishonorableDischargesarenoteligibleforVICprograms
2
IfyouhaveservedinaCombatZone,WWIIKoreaVietnamDesertStorm OIF OEF
pleasecheck
Other(explain)________________________________________________________
Marital and Emergency Contact
MaritalStatusMarriedSingleDivorcedCommonLawWidowSeparated
Doyouhaveanychildren?
(ifyes,pleaselistnameandlocation)YESNO
__________________________________________________________________________________________
FamilyorEmergencyContactName&Number___________________________________________________
(Ifyoudon’thaveone,youcanlistNONE)
Medical Information
AreyouregisteredorhaveyoureceivedVAHealthcareServices?YESNO
(IfyouhaveaVAIDCardpleaseprovidecopy)
Doyouhaveanyofthefollowing?(checkallthatapply)
Medicare Medicaid Tricare PrivateInsurance NoInsurance
Doyouhaveanyphysicaldisabilitiesorlimitations?(ifYES,pleaseexplainorputNO)
__________________________________________________________________________________________
Doyouneedanyspecialaccommodations?(ex.Wheelchair,walker,cane,showerchair,ADAbathroom,etc.)
__________________________________________________________________________________________
Doyouhave,orhavebeendiagnosedwith,anyofthefollowingconditions?(check) 
COPD Asthma Cancer HighorLowBloodPressure HeartProblems
Othermedical:________________________________
Doyou,orhaveyouhad,anyseriousmedicalconditionsorcontagiousdiseases?(ex.Hepatitis,HIV/AIDS,TB,STD,
Shingles)
__________________________________________________________________________________________
Doyouhave,orhaveyoubeendiagnosedwithamentalorbehavioralhealthproblem?(ex.PTSD,Bi‐Polar,
Schizophrenia,Depression,Disorder,etc.)
__________________________________________________________________________________________
Areyouunderthecareofadoctorforanyproblem?(IfYES,pleasespecify&Doctorname)
__________________________________________________________________________________________
3
Pleaselistalllegallyprescribedmedications_____________________________________________________
__________________________________________________________________________________________
Doyouhaveorhaveyoubeendiagnosedwith,asubstanceusedisorderorfeltthatyoustruggledwith
drugsoralcoholatanytimeinyourpastorpresent?AlcoholPrescriptionDrugsIllegalDrugs
Other:_________________________
IfYES,howlonghaveyoubeentakingthemordrinkingexcessively?________________________________
Whenwasthelasttimeyouusedandwhatkind?________________________________________________
Haveyoueverbeeninadrug,alcohol,ormentalhealthtreatmentprogram?(IfYES,whenandwhere)
__________________________________________________________________________________________
Ifcurrentlyenrolled,whenisyouranticipatedgraduationdate?________________________________
AreyoucurrentlyattendinganAAorNAgroup?(Ifyes,howoften)________________________________
Legal
Doyoucurrentlyhaveanyoutstandingwarrantsinanystate?(Ifyes,charge,location,anddateofarrest)
__________________________________________________________________________________________
HaveyoueverbeenconvictedofARSONoraSEXUALOFFENSE?(IfYES,when,where,disposition)
__________________________________________________________________________________________
Haveyoueverbeenarrested,charged,held,orotherwiseplacedinjail,foranylengthoftime?(Ifyes,explain)
__________________________________________________________________________________________
AreyouonProbationorParole?(IfYES,nameandcontact#ofyourparoleofficer)
__________________________________________________________________________________________
Areyourequiredtoregisterasasexoffender?
(IfYES,whatstateandwhen)______________________________
Intentionally Left Blank
4
INCOME
Doyouhaveanyincome?SSI SSDITANFSNAP WICUnemployment
(checkallthatapply) VADisability ChildSupport Alimony
Retirement IncomeJob Other
Ifyoureceiveincome,listamounttype_________________________________________________________
IfOTHER,listtypeandamount________________________________________________________________
Ifemployed,fullorpart‐timepleaselistcompany,location,hourlyrate,andjobtitle
__________________________________________________________________________________________
PERSONAL
AreyouasurvivorofDomesticViolence?YESNOIfyes,whendidthisoccur?____________________
Highestlevelofeducationcompleted?(check)
GED HSDiploma VocationalCertificateAssociates Bachelors Masters
Other(explain)_______________________________________________________________________
Doyouhaveavehiclewithyou?YESNO*IfYES,pleaseprovidecopyofregistrationandinsurancetoVIC
representative
DriverLicenseorStateID#_____________________________State________________________________
ExpirationDate________________________________
Race(checkallthatapply) HawaiianorPacificBlackorAfrican
Asian WhiteAmericanIndian Islander American DeclinetoAnswer
Ethnicity(check) HispanicorLatino NotHispanic DeclinetoAnswer
Icertifytheinformationinmyapplicationistrue,correctandtothebestofknowledge.Ifurtherunderstand
thatifIprovidefalseormisleadinginformationthattheVIChastherighttodenyorterminateservicestome,
and Imay beterminated atany timeif I do not comply with allVICpolicesandregulationsrelatingtothe
EmergencyorTransitionalHousingprograms.
___________________________________________________________________________________
PrintNameofVeteranSignatureofVeteran
IfEmergencyHoused,nameofVICRepresentativehelpingyou____________________________________
Veteran:IfEnrollingwithaPartnerorChild(ren),pleasefilloutpages5‐6
5
Family Members Section
SpouseorDomesticPartner___________________________________________________________________
LAST FIRSTMI
Haveyoueverusedorbeenknownbyanyothername?(Ifyes,pleaselist)___________________________
SSNumber________________________________CellPhone#________________________________
DateofBirth________________________________ Gender Male Female
Transgender Other
AreyouasurvivorofDomesticViolence?YESNOIfyes,whendidthisoccur?____________________
Highestlevelofeducationcompleted?(check)
GED HSDiploma VocationalCertificateAssociates Bachelors Masters
Other(explain)_______________________________________________________________________
Race(checkallthatapply) HawaiianorPacificBlackorAfrican
Asian WhiteAmericanIndian Islander American DeclinetoAnswer
Ethnicity(check) HispanicorLatino NotHispanic DeclinetoAnswer
INCOME
Doyouhaveanyincome?SSI SSDITANFSNAP WICUnemployment
(checkallthatapply) VADisability ChildSupport Alimony
Retirement IncomeJob Other
Ifyoureceiveincome,listamounttype_________________________________________________________
IfOTHER,listtypeandamount________________________________________________________________
Ifemployed,fullorpart‐timepleaselistcompany,location,hourlyrate,andjobtitle
__________________________________________________________________________________________
Do you have any personal problems that you would like help addressing?
__________________________________________________________________________________________
Legal
Doyoucurrentlyhaveanyoutstandingwarrantsinanystate?(Ifyes,charge,location,anddateofarrest)
__________________________________________________________________________________________
6
HaveyoueverbeenconvictedofARSONoraSEXUALOFFENSE?(IfYES,when,where,disposition)
__________________________________________________________________________________________
Haveyoueverbeenarrested,charged,held,orotherwiseplacedinjail,foranylengthoftime?(Ifyes,explain)
__________________________________________________________________________________________
AreyouonProbationorParole?(IfYES,nameandcontact#ofyourparoleofficer)
__________________________________________________________________________________________
Areyourequiredtoregisterasasexoffender?(IfYES,whatstateandwhen)______________________________
To be completed by Parent for Child Under 18 Years of old
Child1___________________________________________________________________________________
LAST FIRSTMI
DateofBirth________________________________ Gender Male Female
Transgender Other
Race(checkallthatapply) HawaiianorPacificBlackorAfrican
Asian WhiteAmericanIndian Islander American DeclinetoAnswer
Ethnicity(check) HispanicorLatino NotHispanic DeclinetoAnswer
Isthechildcurrentlyenrolledinschool?______________________________________________
(ifYES,pleaselistschoolandgrade)
To be completed by Parent for Child Under 18 Years of old
Child2___________________________________________________________________________________
LAST FIRSTMI
DateofBirth________________________________ Gender Male Female
Transgender Other
Race(checkallthatapply) HawaiianorPacificBlackorAfrican
Asian WhiteAmericanIndian Islander American DeclinetoAnswer
Ethnicity(check) HispanicorLatino NotHispanic DeclinetoAnswer
Isthechildcurrentlyenrolledinschool?______________________________________________
(ifYES,pleaselistschoolandgrade)
7
FOR AGENCY USE ONLY
Eligibility GoNo‐GoNotes
VeteranStatus
Income
MentalHealth
SubstanceUse
HomelessStatus
GPDLiaison
(asapplicable)

Veteranis ELIGIBLE INELIGIBLE Dateenrolled______________________________
ProgramofEnrollment EmergencyHousing SITH Bridge H2H
RecommendreferraltoSSVFfordual‐enrollmentYES NO
IfINELIGIBLE,listreasonfordenial_____________________________________________________________
WecertifytheVeteranIS/ISNOTeligiblefortheabovelistedhousingoption(s).Ifenrolled,acasemanager
hasbeenassignedtotheveteran.
_______________________________________ _______________________________________
LCMSignaturePMSignature
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Veterans MUST Read Before Interview

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Completed 27 February 2021

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