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Veterans Agency Referral
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Veterans Agency Referral
UPDATE
There are no updates at this time.
AGENCY REFERRAL FOR SSVF SERVICES
AGENCY INFORMATION:
Your Agency
Your Name
Your Phone
Your Email
CLIENT INFORMATION:
Situation
*
The type of assistance needed is determined by where the client is currently sleeping.
Select One
Rapid Re-Housing: On streets
Rapid Re-Housing: In a shelter
Rapid Re-Housing: GPD Transitional Housing
Prevention: In hotel, doubled up, in treatment program
Prevention: Housed w/Lease, Dispossessory Warrant served
Prevention: Housed, no warrant served (not eligible for SSVF)
Other (see Notes)
DV
Is the client currently fleeing or attempting to flee a domestic violence situation?
Select One
No
Yes
Unknown
Name
Phone
Email
Location
If the veteran did not stay in one of the listed areas last night and last night only, they are outside of PCCI's coverage area.
Select One
City of Atlanta
Fulton County (outside CoA)
DeKalb County
Clayton County
Henry County
Gwinnett County
Rockdale County
Douglas County
DV
Is the veteran fleeing or attempting to flee Domestic Violence?
Select One
Yes
No
Unknown
Income
Total combined gross monthly income for all adult household members. Program income limit is 80% AMI.
HMIS
Veteran's HMIS ID number, if known.
Identifier
If the veteran is not in HMIS, enter their year of birth and/or the last 4 digits of their social security number. DO NOT ENTER THE VETERAN'S FULL SOCIAL SECURITY NUMBER.
Notes
Veteran's address or approximate location, details of situation, or anything that we may need to know to best assist the veteran. Do not include any PHI in your message.
Submit Referral
Please do not fill in this field.
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