Referral and Case Summary Only: Heaven-Sent Community Services & Veterans Assistance uses this form to collect information the client voluntarily provides so staff can make referrals and help the receiving SSVF, VA, HUD-VASH, or housing provider begin its own intake. This form does not determine eligibility, enroll a participant, approve financial assistance, issue a housing voucher, or replace the receiving program’s required forms, privacy notices, releases, or verification process.
HUD-VASH Intake & Eligibility Application
Veteran housing intake, preliminary screening, consent, documentation, referral coordination, and follow-up.
Form term
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Potentially Chronically Homeless |
“Preliminary screen only. Generally refers to a person with a qualifying disability who is currently in shelter, safe haven, or a place not meant for human habitation and has been homeless continuously for at least 12 months, or on at least four occasions in the past three years totaling at least 12 months. Final determination requires required documentation.” va+1 |
HUD-VASH |
“HUD-VASH combines a HUD housing voucher with VA case-management and supportive services. VA and the local Public Housing Agency make final program and voucher decisions.” hud+1 |
Active Duty |
“Full-time duty in the U.S. Armed Forces. National Guard or Reserve service may have different qualifying periods depending on the purpose of the review; VA staff verify eligibility.” |
VA Health Care |
“Care through the Department of Veterans Affairs. ‘Applied’ means an enrollment application has been submitted but may still be pending.” |
VA Social Worker |
“A VA staff member who helps coordinate health, housing, benefits, and supportive services. Listing a contact does not confirm HUD-VASH enrollment.” |
HUD-VASH referral status |
“A referral is a request for VA/HUD-VASH review. It is not an eligibility approval, voucher, or guarantee of housing.” |
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Housing barriers |
“Issues that may make it harder to obtain or keep housing, such as missing ID, income, rental history, transportation, disability accommodations, documents, or landlord requirements. This is used for planning—not to exclude someone.” |
Homeless episodes |
“Separate periods of homelessness. Staff should document the dates, locations, and available verification.” |
Total homeless time |
“The combined length of qualifying homelessness during the stated period; supporting documentation may be required.” |
Household member entering housing |
“A person expected to live with the Veteran in the potential unit. Final household composition is determined through VA/PHA and program procedures.” |
Total monthly household income |
“Gross income received by all household members before deductions. This is a preliminary intake figure; VA/PHA determine countable income and verify documents.” |
Form term |
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HMIS |
“Homeless Management Information System: the local Continuum of Care’s secure system for recording homelessness services and outcomes. Required notices, consent/refusal procedures, and privacy rules apply.” |
Priority level |
“An internal case-management urgency level used to organize follow-up. It does not establish HUD-VASH priority, eligibility, or voucher order.” |
Housing eligibility issues known |
“Information identified for housing-planning or referral coordination. It is not an automatic reason to deny services; apply VA, HUD, PHA, fair-housing, and individualized-review requirements.” |
Confirmation received |
“Confirmation that the receiving agency or provider received the referral—not confirmation of program acceptance, eligibility, or housing approval.” |
Secure email |
“An agency-approved encrypted or protected email process. Ordinary email and a mailto link are not secure for sensitive records or attachments.” |