McBride Pathways for Veterans | Hamilton, Butler, and Warren Counties, Ohio

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Today.

All services are free and confidential. A real person reviews every submission. We will contact you within one business day.

If you are in crisis right now, call the Veterans Crisis Line immediately. 988 · Press 1 · Free · 24/7

Step 1 of 2

Quick Eligibility Check

This takes about 2 minutes. Tell us a little about your situation and we will reach out within one business day to discuss next steps. Everything is confidential.

Basic Information

First Name *

Last Name *

Phone Number *

Email Address

Eligibility Questions

Are you a United States Veteran? *

Yes No Active Duty Family Member of Veteran

Are you currently enrolled in VA health care? *

Yes No Not Sure

What is your current housing situation? *

What is your approximate monthly income? *

No income Under $500 $500 to $1,000 $1,000 to $2,000 Over $2,000

What kind of support are you looking for? (Select all that apply)

Mental health support VA benefits enrollment or claims help Someone to talk to (peer support) Help connecting to services Housing assistance Financial assistance Not sure yet

Is there anything else you want us to know?

Your information is kept strictly confidential and will never be shared without your consent. By submitting this form you agree to be contacted by McBride Pathways for Veterans at the phone number or email provided.

Thank You

We received your information and will contact you within one business day. If you are in crisis right now please call 988 and press 1.

Full Application

Veteran Intake Application

This comprehensive application helps us understand your full situation so we can connect you to the right services. Takes about 10 minutes. All information is confidential.

Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Phone Number *

Email Address

Current Address or General Location

Race / Ethnicity

Primary Language

Military Service

Branch of Service *

Discharge Status *

Years of Service

Era of Service

Are you currently enrolled in VA health care?

Yes No Applied but not yet enrolled Not Sure

Do you receive any VA disability compensation?

Yes No Claim Pending

Current Housing Situation

Current Housing Status *

How long have you been in your current housing situation?

Income and Employment

Current Income Sources (Select all that apply)

Employment (full or part time) VA Disability Compensation SSI or SSDI Pension SNAP or other food assistance No current income

Monthly Income (approximate)

Current Employment Status

Barriers and Challenges

Mental Health — Are you currently experiencing any of the following? (Select all that apply)

Depression Anxiety PTSD Thoughts of suicide or self-harm Traumatic Brain Injury (TBI) Other mental health challenges None of the above

Substance Use — Are you currently experiencing challenges with?

Alcohol Drugs or controlled substances Prescription medication misuse None Prefer not to say

Legal — Do you have any of the following? (Select all that apply)

Pending criminal charges Currently on probation or parole Prior felony conviction Prior evictions on record None

Other Barriers (Select all that apply)

No ID or identification documents No reliable phone or communication No transportation No health insurance Fleeing domestic violence Childcare needs

Referral and Emergency Contact

How did you hear about McBride Pathways for Veterans?

Do you have a current case manager or social worker?

Yes No

Case Manager Name (if applicable)

Case Manager Phone or Email

Emergency Contact Name *

Relationship

Emergency Contact Phone *

Emergency Contact Email

Is there anything else you want us to know about your situation?

Consent

I consent to be contacted by McBride Pathways for Veterans by phone or email regarding my application and available services. * I understand that my information will be kept confidential and will not be shared without my written consent except as required by law. * I certify that the information I have provided is true and accurate to the best of my knowledge. *

Signature (Type your full legal name) *

Date *

All information is kept strictly confidential in accordance with applicable privacy laws. A staff member from McBride Pathways for Veterans will contact you within one business day.

Application Received

Thank you for trusting us with your information. A member of our team will contact you within one business day. If you are in crisis please call 988 and press 1.

After Intake

Needs Assessment

This form is completed after your intake appointment. It helps us understand what specific support you need so we can build the right service plan for you.

Veteran Information

Full Name *

Date of Assessment *

Case Manager

Assessment Number

Employment Readiness

Are you interested in employment assistance?

Yes No Currently employed

Employment barriers (Select all that apply)

Need help with resume Need skills training or certifications Criminal record affecting employment Physical or mental health disability Transportation to work No barriers

Mental Health and Wellbeing

On a scale of 1 to 10 how would you rate your overall mental health right now? (1 = very poor, 10 = excellent)

Are you currently receiving mental health treatment?

Yes No On a waitlist

Mental health support needed (Select all that apply)

Individual therapy or counseling Medication management Peer support Safety or crisis plan Substance use treatment None at this time

Life Skills and Daily Living

Areas where you would like support (Select all that apply)

Budgeting and financial management Cooking and nutrition Transportation and getting around Technology and computer skills Social skills and community connection Navigating VA benefits and government services None at this time

What are your top 3 goals for the next 90 days?

Is there anything else our team should know to help you?

All information is confidential and used only to build your individual service plan.

Assessment Submitted

Your case manager will review your assessment and follow up with you shortly.

Ongoing Support

Progress Update

Used by case managers and enrolled Veterans to track goals, progress, and service plan updates on a weekly or monthly basis.

Veteran and Period Information

Veteran Full Name *

Case Manager Name *

Update Date *

Update Period

Goals and Progress

Current Goals

Progress This Period

Services Provided This Period (Select all that apply)

Peer support sessions Case management VA benefits assistance Referrals to outside services Mental health screening (C-SSRS) Crisis support Transportation assistance Financial assistance or emergency funds

Missed Appointments This Period

Risk and Wellbeing

Current Risk Level (from most recent C-SSRS screening)

Low Moderate High Not screened this period

Change in Risk Level Since Last Update

Improved Same Declined First update

Case Manager Notes

Recommended Next Steps

All case notes are confidential and stored securely for program reporting and grant compliance purposes.

Progress Update Submitted

The update has been recorded. Thank you for keeping case notes current.

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