1. Please enter the information indicated below.
First Name of Veteran or Spouse Who Needs Care:*
Last Name of Veteran or Spouse Who Needs Care:*
Name of Person to Contact*
Person to Contact's Phone:*
Person to Contact's Email Address:*
Veteran Or Spouse's Phone Number:*
State of Veteran or Spouse:*
Zip Code of Veteran or Spouse:*
State State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
2. Are you a provider or senior care professional referring a client/patient?* 2. Are you a provider or senior care professional referring a client/patient?
Company/Organization (please include branch name):*
Referral Source First Name:*
Referral Source Last Name:*
Referral Source Email Address:*
Referral Source Phone #:*
Referral Source City:*
Referral Source State:* Referral Source State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Avoid having to enter your contact information for each referral by downloading our VetAssist app on your tablet or smart phone.
Military Screening Questions
3. Are you a veteran or the surviving spouse of... 3. Are you, or your loved one, a veteran or the surviving spouse of a deceased wartime veteran who needs help to live safely at home? (Surviving spouse must have been married to the veteran at least 1 year and at time of veteran's death. Married couples are only eligible if the veteran is disabled and meets the guidelines.)
Comment
4. Did the veteran receive an honorable or general discharge? 4. Did the veteran receive an honorable or general discharge?
Comment
5. Did the veteran serve at least one day during wartime? 5. Did the veteran serve at least one day during wartime? (Combat duty or overseas service is not required.)
Comment
Word War II:
Korean Conflict:
Vietnam Era:
Persian Gulf War:
6. Did the veteran serve at least 90 days on active duty? (Persian Gulf War veterans must have 2 years of active duty or the full period for which they were called for active duty.) 6. Did the veteran serve at least 90 days on active duty? (Persian Gulf War veterans must have 2 years of active duty or the full period for which they were called for active duty.)
Comment
Medical Screening Questions
7. Does the veteran or surviving spouse have a medical condition causing the need for assistance with some activities of daily living? 7. Does the veteran or surviving spouse have a medical condition causing the need for assistance with some activities of daily living? (Examples are: help with bathing, dressing, grooming, using the bathroom, meal preparation, and moving about safely.)
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8. Is the veteran or surviving spouse 65 years old or older? (You may also check “yes” if younger than 65, and has a letter from Social Security proving a disability.) 8. Is the veteran or surviving spouse 65 years old or older? (You may also check “yes” if younger than 65, and has a letter from Social Security proving a disability.)
Comment
9. Does the veteran or surviving spouse want to use his/her VA Pension with Aid & Attendance primarily for in-home care or adult daycare? 9. Does the veteran or surviving spouse want to use his/her VA Pension with Aid & Attendance primarily for in-home care or adult daycare? (In-home care is non medical care such as help with bathing, dressing, light housekeeping, meal preparation, medication reminders and more.)
Comment
Monetary Screening Questions
10. Regarding any monetary benefits from the VA that you already may receive, is the sum: 10. Regarding any monetary benefits from the VA that you already may receive, is the sum:
-- if veteran, between $0 - $1,000,
(If known, please indicate the monthly amount you receive from the VA in the comments below.) Comment
11. Does he/she or this couple have a total net worth (income & assets) at or less than $130,773? 11. Does he/she or this couple have a total net worth (income & assets) at or less than $130,773?(A primary residence and vehicle are not counted as part of net worth. Ongoing, un-reimbursed medical expenses and long-term care expenses can be deducted from net worth. If known, please indicate monthly income and estimated total assets in the comments below.)
Comment
If you answered "Yes" to all of these questions, it appears you or your loved one may be eligible for the VetAssist Program and the VA's Pension with Aid and Attendence. 888-314-6075 to learn more and continue the process. If you answered "No" to any of these questions, it appears you are not eligible for the VetAssist Program. You may want to contact a veteran service organization for help with your VA benefits.If you answered "Unsure" to any of these questions , you may want to call us at 888-314-6075 or email us at info@veteranshomecare.com or visit our website www.veteranshomecare.com to learn more.The VetAssist®️ Program is an exclusive offering of the Veterans Home Care®️ family of companies. Veterans Home Care®️ and the VetAssist®️ Program are not part of any government agency and are not affiliated with the Department of Veterans Affairs.
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