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.

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Family Member Contact Information





Please select your Service Rank if applicable








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Caregiver Contact Information





Please select your Service Rank if applicable








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Veteran's Contact Information










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Veteran & Household Information



(Example, 4/25/2003)



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Please enter the age(s) in number separated by comma

Veteran's Military Service Data




(Example, 4/25/2003)

(Example, 4/25/2003)



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Veteran's Health-Care



Veteran's Housing and Transportation


Veteran's Employment & Income

Initial Needs Request

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1000 characters or less

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.





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.


Quality of Life Assessment

Instructions: This questionnaire asks for your views about your health.  This information will help keep track of how you feel and how well you are able to do your usual activities.

 

Answer every question by marking the answer as indicated.  If you are unsure how to answer a question, please give the best answer you can.


*2.  The following questions are about activities you might do during a typical day. Does your health now limit you in these activities?  If so, how much?


3.  During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?


4.  During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?



These questions are about how you feel and how things have been with you during the past 4 weeks.  For each question, please give the one answer that comes closest to the way you have been feeling.
*6.  How much of the time during the past 4 weeks:




Now, we'd like to ask you some questions about how your health may have changed.


This survey was developed at RAND as part of the Medical Outcomes Study.
*Modifications made by Code of Support Foundation.

Contact Information