Referral Submission Form

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eligibility for programs varies and may depend upon the character of discharge.

However, We encourage all Veterans
to apply, as we offer diverse programs with different
APPROVAL criteria.

VIC PROGRAM REFERRAL FORM

Basic Information

First name*

Last name*

Date of birth:*

Phone

SSN*

Email

Preferred Method of Contact*

Email

Phone

Which Program Are You Applying For?

Supportive Services for Veteran Families (SSVF)

Grant & Per Diem (GPD) (Transitional Housing)

PHOENIX RISING (Suicide Prevention / Mental Health) (SSGPF)

Unsure

Referred by an Agency?*

Yes

No

If yes, please enter the Agency name, phone number, and date they referred you if you know it:

Veteran Eligiblity

Are you a veteran of the US Armed Forces?*

Yes

No

Branch(es)?*

Honorable Discharge? (Cannot be dishonorable)

Yes

No

Other

Housing Status

Choose the following:

Homeless (street/shelter)

Facing eviction / at risk of homelessness

Transitional Housing

Other

Household Snapshot

Number of adults:*

Number of children: (under the age of 18)*

Income (Basic Eligibility)

Monthly Income Estimate*

Income Type

Job

Veterans Affairs (VA)

SSI/SSDI

None

Immediate Needs / Barriers

Check any urgent concerns:

Mental Health

Substance Abuse

Medical Issues

No income

Transportation

Safety Concerns

Suicide Ideation

Other (Please provide a brief explanation)

Albuquerque Campus
2701 Mulberry St. SE,

Albuquerque, NM 87106

Phone: (505) 296-0800
Fax: (505) 332-8092

CONTACT US

Thanks for submitting!

The Veterans Integration Centers (VIC) makes records of open meetings available to the public. Copies of meeting minutes may be reviewed in person at VIC offices during normal business hours, Monday through Friday.

The Veterans Integration Center (VIC®) is a 501(c)(3) organization, and all donations are tax deductible.

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eligibility for programs varies and may depend upon the character of discharge. However, We encourage all Veterans to apply, as we offer diverse programs with different APPROVAL criteria.