2026 Intake - National Association of Veterans & Families

NAVF Intake (Standard Multi-Section)

NAVF Intake

Applying for VA benefits can be confusing and exacting. We will complete the lengthy application for you from
the information that you provide on the following questionnaire.

Answer all questions completely.

If you need to obtain additional information, you can leave this form and come back at a later time.

Consent / Disclosure

I understand and wish to continue

Your Information

This is the person we should contact about this intake.

First Name

Last Name

Your relationship to the veteran

Your Phone

Your Email

Veteran Information

Is the veteran living?

Yes

No (deceased)

If deceased, date of death (if known)

Veteran Full Name

Veteran Date of Birth

Where the Veteran Lives Now

Use the address where the veteran sleeps most nights right now.

Current Living Address (where veteran sleeps most nights)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Is this a facility?

Yes

If yes, what type of facility?

Mailing Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Spouse / Partner

Is there a spouse/partner relevant to this intake?

Yes

Spouse/Partner Status

Living

Deceased

Spouse/Partner Full Name

Spouse/Partner Date of Birth

Is the spouse living with the veteran?

Yes

Not applicable

If spouse is deceased, date of death (if known)

Military Service

Branch of Service

Dates of Service (approximate is OK)

Wartime Service?

Yes

Unsure

Character of Discharge (if known)

Do you have a copy of the DD-214?

Yes

Unsure

VA File Number (if known)

Health & Care Needs

Primary diagnoses (if known)

Currently receiving paid home care services?

Yes

Unsure

If yes, hours per week (approx.)

Housing & Property

Does the veteran (or spouse) own a home?

Yes

Unsure

Estimated home value (if known)

Mortgage balance (if any)

Planning to sell the home?

Yes

Unsure

If selling, expected timeframe

Monthly Income (Gross)

Enter approximate monthly amounts. If unknown, leave blank.

Veteran: Social Security ($/month)

Veteran: Pension ($/month)

Veteran: Other Income ($/month)

Spouse: Social Security ($/month)

Spouse: Pension ($/month)

Spouse: Other Income ($/month)

Assets (Approximate)

Checking/Savings ($)

Investments/CDs/Stocks/Bonds ($)

Retirement Accounts (IRA/401k) ($)

Cash on hand ($)

Other assets ($)

Monthly Care Expenses

Home care or facility cost ($/month)

Medical out-of-pocket ($/month)

Prescriptions ($/month)

Other care-related costs ($/month)

Urgency Indicators

Check any that apply

At risk of eviction/homelessness

Unable to afford current care

Imminent facility placement

Caregiver burnout / unsafe situation

No family support

Previous VA Benefits

Currently receiving VA benefits?

Yes

Unsure

If yes, which benefits? (optional)

Optional Services Interest (Optional)

These services are optional and separate from free claims assistance.

Check any you would like more information about

Caregiver & Care Planning Navigation Session

Veteran Records Digitization & Organization

Family Education Workshop

Assisted Living / Home Care Placement Advisory

Comprehensive Care Navigation Package

None at this time

Documents (Optional)

If available, you may upload helpful documents (DD-214, care invoices, etc.).

Upload Documents (optional)

Choose File

Authorization

I certify the information provided is true and accurate to the best of my knowledge. I understand optional services are not required.

I agree