SCG VETERAN INTAKE FORM

First Name

Last Name

Address

Phone

Are You Currently Experiencing Homelessness or in Danger of Becoming Homeless?

Marital Status

Alternate Contact First and Last Name (Trusted Person SCG can contact in Emergency.)

Alternate Contact Relationship to You

Alternate Contact Phone Number or Email Address

Military Branch

Type of Discharge

Do you have your Military Medical/Service Treatment Records?

Yes, and I will send/upload.

No, please request on my behalf.

Surgeries, Injuries, Broken Bones, Hospitalizations During Service. List type and year.

Main Source of Ailment/Discomfort

Date Entered Regular Active Duty Service

Month

Day

Year

Date Separated from Regular Active Duty Service

Month

Day

Year

If Currently Active Duty, What is Your Projected Retirement/Separation Date?

Were you Deployed Overseas After August 2, 1990?

Indicate the Locations You Were Stationed.

. Any combat exposure or combat theater (special ops)? Any deployment(s) to Southwest Asia? List location(s) and date range(s).

DID YOU SERVE IN ANY GULF WAR HAZARD LOCATIONS? (Iraq; Kuwait; Saudi Arabia; Neutral Zone; Bahrain; Qatar; UAE; Oman; Yemen; Lebanon; Somalia; Afghanistan; Israel; Egypt; Turkey; Syria) If yes, list locations and dates.

HERBICIDE (AGENT ORANGE) LOCATIONS? (Vietnam including 12 nm waters; Thailand bases; Laos; Cambodia—Mimot/Krek/Kampong Cham; Guam).If yes, list locations and dates.

Have you Ever Filed a VA Disability Claim?

If So, What Is Your Combined Disability Rating?

Are You Currently Employed? If Yes, How Many Hours Per Week?

Personal Referral-If Someone Referred You, Please Let Us Know Who to Thank.

Have you started working with one of our SCG case managers?

Disclaimer: This form does not request Social Security numbers, banking information, or full dates of birth. Information submitted is used solely to determine service eligibility and respond to inquiries. Submission of this form does not establish a client relationship or guarantee outcomes.