Form – VetAssist ApplicationMatt Auman2020-07-28T16:54:57-04:00

VetAssist New Client Application

VetAssist New Client Referral Form

Introduction

Thank you for your interest in our veteran's home care program.  Please complete as much of this information as you can.  We will forward it to our partner, Veterans Home Care, to begin the eligibility screening.  Someone from their organization will contact you within the next 48 hours to continue the process.

Referring Person's Name *

Referring Person's Phone #

Referring Person's Email

Select Branch/Office Location *

Today's Date *

PROSPECTIVE CLIENT INFORMATION

Applicant Name *

Phone #1 *

Phone #2

Address *

Address

City

State/Province

Zip/Postal

County *

Date of Birth *

Check which applies *

Applicant is a VETERAN

Applicant is a SURVIVING SPOUSE of a Veteran

WAR PERIOD SERVED *

WWII

KOREAN

VIETNAM

OTHER

If the veteran did not serve during wartime, the applicant WILL NOT qualify for the "Aid and Attendance pension. The VA defines wartime periods as follows: World War II: December 7, 1941 to December 31, 1946 Korean Conflict: June 27, 1950 to January 31, 1955 Vietnam Era: August 5, 1964 to May 7, 1975 Or served in the country of Vietnam February 28, 1961 to August 5, 1964 Persian Gulf War: August 2, 1990 to (date to be determined).

If you selected "Other", please indicate the war period served.

If applicant is a SURVIVING SPOUSE was applicant divorced from veteran at time of veteran's death?

Yes

N/A

If the answer to the above question is "yes" the applicant WILL NOT qualify for the "Aid and Attendance" pension.

Is applicant driving? *

Yes

Applicant needs help with: Check all that apply *

Bathing

Dressing

Toileting/Continence

Walking

Meal Preparation

Notes: any additional information you would like to share with us.

Is applicant currently receiving a VA pension or VA compensation? *

Yes

If you are human, leave this field blank.

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