I Don't See My City

If you know of anyone who may benefit from the Aid and Attendance program, we can help determine if they are eligible for this benefit.

Referral Form: Click on the referral form to download a fill in form to fax to Veterans Care Coordination.

Download Our Referral Form

Client Information
Client's Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Client's Phone
Client's Email
Veteran Information
Veteran Status
Was the Veteran honorably discharged?
Did the veteran serve at least 90 consecutive days of active duty, with at least one day during any of the following wartime periods?
Please select the wartime period that the veteran served:*
Surviving Spouse Information
Were you married to the veteran at the time of death?
Did you remain unmarried after the Veteran's death?
Care Needs
Please select any of the Activities of Daily Living that require assistance:
(hold down Ctrl button while selecting values)
Are assets less than $150,538?
Is the client currently receiving services from your organization?
Is assisted living or nursing home care being considered within 60-90 days?
Is the veteran or surviving spouse already receiving VA money?
Alternate Contact Information
Alternate Contact
Relation to Contact
Alternate Contact Phone
Alternate Contact Email
Referral Information
Referring Contact*
First Last
Referring Organization*

Type "None" if you are not affiliated with an organization.
Referring Phone
Referring Email
Additional Information
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