RVCP Veteran Family Intake Assessment - Primary Member Attending Intake

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* 1. Which county in Nebraska do you live?

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* 2. Please identify the type of assistance you want help with. If you are not currently in search of services, which of the resources below would help you in your day-to-day life (check all that apply):

Health Care (excluding Mental Health) (Health care includes doctors’ offices, emergency rooms, outpatient clinics, Family Health Centers, etc.)

Mental Health Services (Mental Health Care includes individual or group counseling, psychiatrist or psychologist offices, psychiatric inpatient services, Community Mental Health Centers, etc.)

Substance Abuse Programs (Substance Abuse Programs include Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, hospital “detox” programs, outpatient substances abuse programs, Alcohol and Drug Treatment Centers, etc.)

Education (Education includes continuing adult education, programs to obtain GED, community college courses, college courses, on-line educational courses, etc.)

Training (Includes job training, apprenticeships, mentoring programs ,training grant programs, etc.)

Transportation (Transportation includes buses, trains, Veteran Service Organization, e.g., Disabled American Veterans, vans, etc.)

Employment/Job (Includes services for job search, filling out applications, creating resumes, etc.)

Family support (Includes nutrition programs, food banks, State and local government income assistance, Support Groups, respite care, etc.)

Child care (Child care includes daycare, after school programs, summer camps, etc.)

Housing Assistance (Housing Assistance includes utility assistance programs, subsidized housing programs, Veterans Home Loan Guaranty benefit, etc.)

Marital Counseling (Marital counseling includes individual, couples or group settings to alleviate problems in the home)

Financial Management (Financial management include debt reduction or consolidation services, budget planning, tax preparation, etc.)

Recreational Services (Community sport teams, libraries, theatre, golf courses, swimming pool, etc.)

Other (please specify)

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* 3. Are the services requested today for the Veteran, yourself, or your family? (Check all that apply)

Veteran

Self

Family