Veterans’ Needs Assessment Veterans' Needs Assessment 1. I am a:*VeteranSpouse/Partner of VeteranChild of VeteranCaregiver of VeteranNot applicable2. My gender is:*MaleFemaleTransgender Female/FeminineTransgender Male/MasculineGenderqueerPangender3. My sexual orientation is:*AsexualBisexualGayHeterosexual/StraightLesbianPansexualQueerQuestioning4. My ethnicity is:*Hispanic/LatinxNon-Hispanic/Latinx5. My race is: (check all that apply)* American Indian or Alaskan Native Asian Black/African American Native Hawaiian/Pacific Islander White 6. My age group is:*13-1718-2728-4445-5960-8485+7. My employment status is:*EmployedRetired - not disabledRetired - disabledUnemployedUnder-employedStudent8. My branch of service is/was:*Air ForceArmyCoast GuardMarinesNavyNational GuardReservesNot applicable9. My discharge status is:*Honorably dischargedLess than honorably discharged (does not affect accessing services)Active duty militaryNot applicable10. My discharge was due to a medical condition:YesNo11. I receive benefits through the Veterans Administration:*YesNoNot Applicable12. I do or did receive benefits/services from another Veteran's assistance program:*YesNoNot applicable13. Please describe any benefits received if you answered yes to question 12:14. My healthcare is paid through: (check all that apply) Veteran's Administration Champus/Tricare Private employer insurance Marketplace insurance Medicare Medicaid Harris Health System Federally Qualified Health Clinic (non-profit) I do not have access to any resources for healthcare 15. I have been treated for a mental health condition:YesNo16. I have been treated for a substance use disorder:YesNo17. I have a permanent place to live:YesNo18. If you answered no to question 17, please describe your living situation:19. I receive these services from any source: (check all that apply) Primary care/medical Dental Vision Hearing Mental health counseling Substance use disorder counseling Case management Food Transportation - bus/rail/gas voucher Transportation - van pick-up Housing financial support Employment services Educational/Vocational training Legal assistance Budgeting/Money Management Upgrading disability assessment 20. I need these services but have not been able to obtain them: (check all that apply) Primary care/medical Dental Vision Hearing Mental health counseling Substance use disorder counseling Case management Food Transportation - bus/rail/gas voucher Transportation - van pick-up Housing financial support Employment services Educational/Vocational training Legal assistance Budgeting/Money Management Upgrading disability assessment 21. I am able to meet my financial obligations and living expenses:YesNo22. I am able to sustain a good quality of life:YesNo23. My most urgent unmet need is:24. I have encountered these barriers to receiving services: (check all that apply) Not aware of where to get services Transportation difficulties Discrimination Not eligible Wait lists Quality of the services available Confidentiality problems If you have already completed the Interpersonal Support Evaluation List, skip to the last question. This scale is made up of a list of statements each of which may or may not be true about you. For each statement check "definitely true" if you are sure it is true about you and "probably true" if you think it is true but are not absolutely certain. Similarly, you should check "definitely false" if you are sure the statement is false and "probably false" if you think it is false but are not absolutely certain.ISEL-12 Q1, If I wanted to go on a trip for a day (for example, to the country or mountains), I would have a hard time finding someone to go with me.definitely falseprobably falseprobably truedefinitely trueISEL-12 Q2. I feel that there is no one I can share my most private worries and fears with.definitely falseprobably falseprobably truedefinitely trueISEL-12 Q3. If I were sick, I could easily find someone to help me with my daily chores.definitely falseprobably falseprobably truedefinitely trueISEL Q4. There is someone I can turn to for advice about handling problems with my family.definitely falseprobably falseprobably truedefinitely trueISEL Q5. If I decide one afternoon that I would like to go to a movie that evening, I could easily find someone to go with me.definitely falseprobably falseprobably truedefinitely trueISEL Q6. When I need suggestions on how to deal with a personal problem, I know someone I can turn to.definitely falseprobably falseprobably truedefinitely trueISEL Q7. I don't often get invited to do things with others.definitely falseprobably falseprobably truedefinitely trueISEL Q8. If I had to go out of town for a few weeks, it would be difficult to find someone who would look after my house or apartment (the plants, pets, garden, etc.).definitely falseprobably falseprobably truedefinitely trueISEL Q9. If I wanted to have lunch with someone, I could easily find someone to join me.definitely falseprobably falseprobably truedefinitely trueISEL Q10. If I was stranded 10 miles from home, there is someone I could call who could come and get me.definitely falseprobably falseprobably truedefinitely trueISEL Q11. If a family crisis arose, it would be difficult to find someone who could give me good advice about how to handle it.definitely falseprobably falseprobably truedefinitely trueISEL Q12. If I needed some help in moving to a new house or apartment, I would have a hard time finding someone to help me.definitely falseprobably falseprobably truedefinitely trueLastly, if you would like someone to contact you about services or social support, please list your name, phone number and email.
