Client Forms Center Heaven-Sent Client Forms Center Unified packet of intake, telehealth, wellness, follow-up, satisfaction, and closure tools for Heaven-Sent Community Services Veterans Assistance. Prepared for Heaven-Sent Designer Joseph Ryan Date April 14, 2026 On this page Routing 0 VA Intake Release 1 Telehealth Consent 2 Wellness Check 3 Follow-Up Check-In 4 Satisfaction Survey 5 Case Closure Summary 6 Submit / Print 7 Routing and Staff Assignment These values help the shared PHP handler decide who gets the staff copy and where the packet is grouped. Client or packet label Staff completing packet Send staff copy to Joe Tim Teresa Darrell Case number The page sends formtype=full_forms and recordgroup=forms to the central PHP handler automatically. VA Intake Release of Information Starting point for new veteran or family intakes with consent to share information. Veteran name Date of birth Phone number Email address Current address Release of information agencies / partners Client veteran signature Signature date Telehealth Video Session Consent Use when services are provided by phone, video, or other telehealth tools. Client name Date of birth Phone number Email address Location where client will usually be during telehealth Services to be provided by telehealth Casework coordination Disaster support VA benefits navigation Counseling / peer support Faith / pastoral care Other If other, briefly describe Risks and limitations reviewed Client or representative signature Signature date Relationship to client if not client Heaven-Sent staff name Wellness Safety Check Quick scan of safety, basic needs, and supports. Date of wellness check Completed by staff Living situation Immediate safety concerns Basic needs today Supports and strengths Follow-Up Check-In Use for phone or in-person check-ins after the initial visit. Follow-up date Completed by staff Contact type Updates since last contact New needs or requests Planned next steps Client Satisfaction Snapshot Brief, friendly check on how services are going. Overall, how satisfied are you with the support from Heaven-Sent? What has been most helpful? What could we do better? Would you recommend Heaven-Sent to another veteran or family? Case Closure Summary Short summary when a case is resolved, transferred, or paused. Client name Case number Primary worker Date opened Date closed Primary reason for closure Reason description Key services provided Housing / shelter Disaster relief / recovery VA benefits navigation Counseling / peer support Financial / material assistance Other Progress toward goals Referrals at closure Follow-up recommended Worker completing summary Sign-off date Submit, Save, Email, Print This will save the packet to the server, email a staff copy, and show a printable confirmation page. Packet preview Packet preview will appear here when you click refresh preview or submit. Refresh Preview Submit Packet, Email Staff Copy, Open Confirmation Print Current Page When you click submit, the page will send the packet to the shared Heaven-Sent server handler and open the confirmation page.
