Application

VA Pittsburgh Healthcare System
1010 Delafield Road, Building 69
Phone: 412-822-1300
1-866-4VA-PITT

Veterans Recovery Center
Pittsburgh, PA 15260
FAX: 412-822-1290(DOM)
412-822-1289(HCHV)

***TO BE COMPLETED BY THE VETERAN WHO IS APPLYING FOR SERVICES***

Veteran's Information

Name(Required)

First Last

Social Security #(Required)

Contact Phone(Required)

DOB(Required)

Cell Phone(Required)

Whom may we contact in case of emergency?(Required)

Emergency Contact Phone(Required)

Where are you currently staying?(Required)

Own Home/apartment

Friend’s Home/apartment

Parent’s Home/apartment

Shelter

Other

Name of Shelter

Other

How much longer can you stay where you are currently living:(Required)

When was the last time you lived independently?(Required)

What program are you applying for?(Required)

Domiciliary

HCHV Transitional Housing

Veteran’s Place

Shepherd’s Heart

Mechling Shakley Veterans Center (268)

Coraopolis

HUD-VASH

PRRTP/CWT Housing

Military

Branch of the Service(Required)

Dates of Service(Required)

Highest Rank(Required)

Rank at Discharge:(Required)

Type of Discharge:(Required)

In Combat(Required)

Yes

No

If Yes, When and Where

Service Connected %:(Required)

What is your SC disability?(Required)

Do you currently have a claim pending for VA benefits?(Required)

Yes

No

Please explain:(Required)

Self Assessment

To Assist Staff in Developing Your Plan of Care, Please Answer These Questions:

What Are Your STRENGTHS?(Required)

What Are Your LIMITATIONS?(Required)

What Are Your NEEDS?(Required)

What Are Your ABILITIES?(Required)

What Are Your INTERESTS?(Required)

GOALS

What Are Your Recovery Goals?(Required)

What Are Your Housing Goals?(Required)

What Are Your Employment Goals?(Required)

Please Read the Following and Check Before Signing This Application:

I Understand and Agree That Providing False Information on This Application May Result in My Not Being Accepted or, If Accepted, Receiving an Irregular Discharge From Programming.(Required)

I Agree

I Understand and Agree That I Will Be Required to Be Drug and Alcohol Free to Gain Admission Into, and to Continue in This Program. I Understand That I Must Submit to Urine Drug and Alcohol Testing at Admission and Randomly Throughout My Stay in the Program.(Required)

I Agree

I Understand and Agree That I and/or My Belongings Will Be Searched Upon Admission, and at the Discretion of VA Staff for Illegal Paraphernalia and Contraband.(Required)

I Agree

I Understand and Agree That if Accepted, a Medical Exam Will Be Completed on My Scheduled Admission Date Before I Am Admitted to Ensure I Am Medically Appropriate to Participate in the Program.(Required)

I Agree

I Understand That Surveillance Cameras Monitor the VA Medical Center Property and the Veterans Recovery Center for the Purpose of Security and Safety of Visitors and Staff. If Accepted Into the Domiciliary Care Program, I Understand That the Residential Villas (Living Room and Kitchen Area) Are Equipped With Video Surveillance Cameras for the Purpose of Security and Safety of Residents and Staff.(Required)

I Agree

Veteran's Signature(Required)

Date(Required)

VA Pittsburgh Healthcare System

Domiciliary

Residential Villas Living Agreement

Security & Safety

I agree I will ALWAYS exit and enter the Villa complex through the MAIN Domiciliary Building Lobby.
I agree I will ALWAYS sign in and sign out at the Lobby Desk in the MAIN Building.
I agree I will remain in my apartment between the hours of 11:00PM and 6:00AM unless I have staff approval to exit the building.
I agree I will not tamper with or interfere with any security devices or video surveillance systems in the Domiciliary buildings.
I agree I will not give my apartment key card to other residents or visitors and I will report immediately to staff if it is lost.
I agree I will not permit non-program visitors in my apartment at any time.
I agree I will have my visitors sign in and out at the MAIN Building Lobby Desk.
I AGREE I WILL NOT SMOKE inside any of the DOMICILIARY Buildings.
I agree I will not engage in any form of sexual activities with visitors, other residents or VA staff on VA property.
I agree to have my personal electrical devices approved by staff before using.

Living Arrangements

I agree to keep my personal room area neat and clean at ALL times.
I agree to perform my assigned chores within my apartment to keep the living environment clean and orderly.
I agree to unannounced inspections of my living environment and personal effects.
I agree not to abuse, misuse, steal or deliberately damage VA property.
I agree to report to VA staff any maintenance issues in a timely manner.

As a resident of the Domiciliary Residential Villa Community I understand and agree to these program rules and I also understand violation of any of these rules WILL result in disciplinary action and possibly discharge from the program.

(See Code of Conduct)

Resident's Signature(Required)

Date(Required)

Staff Witness Signature(Required)

Date(Required)

FILL OUT AND SUBMIT AN APPLICATION

Application for Comprehensive Homeless Programs

Veteran's Information

Military

Income and Employment

Family and Education

Medical Health History

Mental Health History

SUICIDE RISK ASSESSMENT: YOU MUST ANSWER THESE QUESTIONS!!!

Substance Abuse History

Legal History

Self Assessment

VA Pittsburgh Healthcare System

Domiciliary

Residential Villas Living Agreement

Security & Safety

Living Arrangements

(See Code of Conduct)

INTERVIEW WITH VA SOCIAL WORKER