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Intake Application
Intake Form
First Name
*
*
Last Name
*
*
Email
*
*
*
Phone Number
*
*
ZIP
*
*
Select Individual Classification
*
Veteran
Active Duty Member
Veteran Family Member
Active Duty Family Member
Is the Veteran/Active Duty Service Member currently enrolled in the SSG Fox Program?
Is the Veteran/Active Duty Service Member currently enrolled in the SSG Fox Program?
No
Is the Veteran/Active Duty Service Member currently enrolled in the SSG Fox Program?
Yes
Veterans First Name
*
Veterans Last Name
*
Demographics
Age at present
*
18-24
25-34
35-44
45-54
55-64
65+
Race/Ethnicity
*
Please select Hispanic, Latino, or Spanish origin
What is your sex assigned at birth?
*
Male
Female
Gender X
Unsure
Prefer not to answer
What is your gender identity?
Do you identify as transgender?
*
Yes
No
Prefer not to answer
Marital Status
*
Married or Domestic Partner
Divorced
Single
Never Married
Previously married and separated
Widow/Widower
Family Service History and VA Benefits Review
Are you currently serving in the United States Military?
*
Are you currently serving in the United States Military?
No
Are you currently serving in the United States Military?
Yes
If you previously served or are currently serving, what was/is your most recent branch of service (Please select the parent service for Guard and Reserve personnel)
*
Army
Navy
Air Force
Marines
Coast Guard
Space Force
Public Health Service
National Oceanic and Atmospheric Administration
Other
Not applicable
In what era did you or are you serving?
Please select your most appropriate discharge category
*
Honorable
General under Honorable Conditions
Other than Honorable
Bad Conduct
Dishonorable
Entry Level or Non-Characterized
Not applicable
Did you sustain any physical or mental disabling injuries during your military service?
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Yes
No
Not applicable
Have you received a VA Service-Connected Disability rating?
*
Yes
No
Pending
Not applicable
What is your total combined VA Service-Connected Disability rating?
*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Not applicable
Do you receive a VA Pension?
*
Yes
No
Pending
Not applicable
Are you enrolled in VA Healthcare?
*
Yes
No
Pending
If eligible, are you interested in using VA Healthcare?
*
Yes
No
Undecided
Prefer not to answer
Not applicable
Please indicate which VA benefits, if any, you have ever received?
When, if any, was the last time you received a VA service or benefit?
*
Within the last year
More than one year
Not applicable
Do you have Health Care insurance?
*
Do you have Health Care insurance?
No
Do you have Health Care insurance?
Yes
What type of Health Care Insurance do you have?
Referral, Outreach and Previous Suicide Prevention Services
Were you referred to the SSG Fox SPGP?
*
Were you referred to the SSG Fox SPGP?
No
Were you referred to the SSG Fox SPGP?
Yes
Referring Organization/Entity
*
VA staff
Military personnel
University/College staff
Family physician
Family or friend
Church
Community based organization
Veteran Service Organization
Not applicable
Referring Organization/Entity Location Zip Code
*
Did you find out about SSG Fox SPGP as a result of an Outreach and Engagement Event?
*
Did you find out about SSG Fox SPGP as a result of an Outreach and Engagement Event?
No
Did you find out about SSG Fox SPGP as a result of an Outreach and Engagement Event?
Yes
Outreach and Engagement Event
Outreach Event Location Zip Code
*
Date of Event
*
Do you have any challenges that could limit your participation in the program?
*
Do you have any challenges that could limit your participation in the program?
No
Do you have any challenges that could limit your participation in the program?
Yes
Please select the challenges that best explain
Have you previously received any of the following suicide prevention services?
