Client Intake Form
Veteran Housing · Clark County, NV
First Name*
Last Name*
Date of Birth*
Gender
Phone Number*
Alternate Phone
Email Address
Primary Language
Branch of Service*
Years of Service (e.g. 2004–2012)
Discharge Status
Has DD-214 Available?
VA Disability Rating
Enrolled in VA Healthcare?
VA / Veteran Programs (select all that apply)
VA Case Manager Name & Phone
Current Living Situation*
How long without stable housing?
Last Permanent Address (City)
Reason for Losing Housing
Desired Move-In Date
Previous Evictions or Landlord Issues?
Current Income Sources (select all that apply)
Monthly Income Amount ($)
Current Benefits (select all that apply)
Has Rep Payee / VA Fiduciary?
Diagnosed Conditions (select all that apply)
Substance Use History
Date of Last Use
Currently in Treatment / Recovery?
Currently on Medication?
Recent Hospitalization?
Physical Health / Disabilities / Mobility Needs
Any Criminal History?
Currently on Probation or Parole?
Probation / Parole Officer Name
PO Phone Number
Sex Offender Registry?
Arson History?
Criminal History Notes
Emergency Contact Name
Emergency Contact Phone
Relationship
Referral Source
Referring Person / Agency
Referrer Phone / Email
Additional Notes
I confirm the information above is accurate to the best of my knowledge.*
Full Name (signature)*
Date*
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