Case Coordination Client Application

Thank you for reaching out to Code of Support Foundation. In order to better assist you, please fill out the following form to have an intake coordinator contact you. Please note that Code of Support Foundation is committed to protecting your privacy and information you provide will not be shared with third parties.

Let's Get Started

How did you hear about us?

Name of Organization/Institution

Military Affiliation (Select One):

Family Member Contact Information

First Name

Last Name

Relationship to Veteran

I am also a Veteran/Service Member

Service Rank

Please select your Service Rank if applicable

Branch of Service

Address

City

State

Zip Code

County

Phone

Enter number without extra characters

Mobile

Enter number without extra characters

Preferred Method of Contact

Caregiver Contact Information

First Name

Last Name

Relationship to Veteran

I am also a Veteran/Service Member

Service Rank

Please select your Service Rank if applicable

Branch of Service

Address

City

State

Zip Code

County

Phone

Enter number without extra characters

Mobile

Enter number without extra characters

Preferred Method of Contact

Veteran's Contact Information

First Name

Last Name

Address

City

State

Zip Code

County

Phone

Enter number without extra characters

Mobile

Enter number without extra characters

Preferred Method of Contact

Veteran & Household Information

Veteran's Race	Veteran's Gender
Veteran's Birthdate (Example, 4/25/2003)	Veteran's Sexual Orientation
Veteran's Marital Status	Total Members in Household Please enter the number value
Do You Have Children	Number of Children Living in Household
Ages of Children Living in Household Please enter the age(s) in number separated by comma	Children 18 and under in Household?

Veteran's Military Service Data

Branch of Service

Service Component

Service Status

Service Start Date

(Example, 4/25/2003)

Service End Date

(Example, 4/25/2003)

Military Occupation

Service Rank

Awards/Decorations

To select multiple items press and hold down the "CTRL" key while making your selections.

Veteran's Health-Care

Eligible for VA Healthcare

Enrolled in VA Healthcare

Service Connected Disability

Disability Rating

Veteran's Housing and Transportation

Current Living Conditions

Mode of Transportation

Veteran's Employment & Income

Employment Status

Initial Needs Request

Please select all areas you need assistance with:

To select multiple items press and hold down the "CTRL" key while making your selections.

Please provide a detailed description of your current circumstance and what you would like assistance with:

1000 characters or less

Previous Assistance?

Have you received ANY help from other organizations? If so please list the organization and what services were provided.

1000 characters or less

Veteran's Documentation

For verification purposes, please upload the following documents. If you are unable to upload at this time, you will be able to provide it to the intake coordinator.

ID (photo of driver's license or other form of ID)

DD214 Document

LES Document

VA Rating Letter

Financials (bills or other related documents)

Service Agreement

This is an agreement between You (client) and Code of Support Foundation. It outlines the expectations, roles, and responsibilities between you and your coordinator throughout the service coordination process. We are dedicated to making each of our clients’ experience with us as positive and productive as possible, but we can’t do it without you. This is going to be a team effort.

Client agrees to the following responsibilities:

I will be honest and will provide accurate information to the best of my ability and knowledge.
I will actively participate and stay engaged throughout the coordination process. For example: I will return phone calls and emails in a timely manner.
I will work together with my coordinator to establish a plan going forward.
I will provide appropriate documentation as requested to facilitate assistance. For example:
- Proof of service - DD214 or LES
- Disability statement letter from the Department of Veterans Affairs
- Bills, eviction notice, etc.
I will make every effort to follow through with the resources my case coordinator provides and report back the results in a timely manner.
I will be respectful and courteous in all communications with my case coordinator(s).

Case Coordinator’s roles and responsibilities:

We will listen to you with respect and empathy.
We will help you prioritize your short/long term needs and goals.
We will identify and help you navigate the resources that can meet your needs to the best of our ability.
We are committed to protecting your privacy and only using your personal information for the purpose of coordinating support services.
We will maintain consistent and timely communication with you.

Our staff is deeply committed to getting you the help you and your family have earned through your service to our country. However, we can’t do it without your cooperation. Failure to adhere to the terms set forth above, may result in termination of case coordination services. By checking the box below, you certify that you have read, understand, and agree to these terms.

Acknowledgement

I have read and agree to these terms

Case Coordination Client Application

Quality of Life Assessment