Heaven-Sent 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 13, 2026 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 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 Staff reminder: Review confidentiality and limits with the client before having them sign. 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 Risks and limitations reviewed Client or representative signature Signature date Relationship to client (if not client) Heaven-Sent staff name Staff reminder: Document where the client is located and how you will reach emergency services if needed. 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 version. Client or packet label Staff completing packet ✔ Submit Packet, Email Staff Copy & Open Print View 🖨 Print Current Page When you click submit, the form will post to the Heaven-Sent server handler and generate a saved staff packet.
