Intake Form Today's Date*Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Are you.. (Select One)*Residing in your own home?Staying with a friend?Living outside?Living in a shelter?Living in a car?How did you hear about Mt. Carmel VSC.. (Select One)*Friend/FamilySocial MediaTVMt. Carmel WebsiteMilitary InstallationMt. Carmel PartnerRadioAge*Gender*MaleFemalePrefer Not to AnswerDate of Birth*EthnicityCaucasianHispanicAfrican AmericanNative AmericanAsian Pacific IslanderMulti RacialHighest Level of EducationHigh SchoolGEDSome CollegeAssociate's DegreeBachelor's DegreeMaster's DegreeDoctorateDegree FieldMarriedSingleMarriedDivorcedWidowedSeparatedChildrenYesNoAge(s)Gender(s)Do you have health insurance?YesNoIf yes, company and typeMilitary InformationBranchGradeMOS/PositionRegistered with Veterans AffairsYesNoDisability Rating*VA RatingMilitary StatusList all years of service*Deployment HistoryService connected disability*YesNoN/AInternet AccessYesNoDischarge Date*Enter N/A if not applicableDo you have access to your DD214?YesNoType of DischargeHonorableDishonorableBad ConductGeneral Under Honorable ConditionsUnder Other than Honorable ConditionsSeparation TypeETSMedicalRetirementAdministrativeCurrently EmployedYesNoEmployerPositionDo you receive state or federal assistance?YesNoNameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.