Veterans Services Pre-Screening Form

If you would like to be screened for Veterans Services eligibility, including the Supportive Services for Veteran Families (SSVF) grant, or would like additional information about resources for veterans, please complete the form below. Your responses will be sent to a Veteran Services outreach specialist, who will contact you within three business days.

First Name

Last Name

Phone Number / Other Ways to Contact You

Alternative Contact Method

Date of Birth

YYYY

Have you served in the U.S. Military (incl. National Guard/Reserves)?

Nature of Discharge

If bad conduct discharge, did it result from:

Did you serve in the Guard or Reserve?

If your answer to the previous question was yes, were you federally activated/activated under title 10?

Please select the response that best describes your CURRENT housing situation:

How many people are in your household? (This number includes those who are or will be living with you.)

Are there any minors (under the age of 18) in your household?

In what county are you seeking services?

Is there any other information you think we should know?