Client ID: __________ Service Date: __________ Type of Service: Outreach Services Case Management Assistance in Obtaining VA Benefits VA Vocational and Rehabilitation Education Assistance Counseling Health Care Services Employment and Training Assistance Assistance in Obtaining or Coordinating Other Public Benefits Health Care Services Legal Services Eviction Prevention – Daily Living Services Legal Services Outstanding Fines and – Personal Financial Planning Services Penalties Transportation Services Legal Services Restore/Acquire – Driver’s License Income Support Services Legal Services Other Fiduciary and Representative – Support Services Child Care Legal Services Child Support Housing Counseling – Direct Provision of Other Public Benefits Personal Financial Planning Services Legal Services Outstanding Fines and – Transportation Services Penalties Legal Services Restore/Acquire Income Support Services – Fiduciary and Representative Driver’s License Support Services Legal Services Other – Legal Services Child Support Child Care – Legal Services Eviction Prevention Housing Counseling – (non-TFA) Supportive Services Approved by VA Financial Assistance Type Rental Assistance Utility Fee Payment Assistance Security Deposit Utility Deposit Moving Cost Transportation Services tokens/vouchers – Transportation Services vehicle repair/maintenance – Child Care General Housing Stability Assistance emergency supplies – General Housing Stability other – Emergency Housing Assistance
Client ID: __________ Service Date: __________ Type of Service: Outreach Services Case Management Assistance in Obtaining VA Benefits VA Vocational and Rehabilitation Counseling Employment and Training Assistance Education Assistance Health Care Services Assistance in Obtaining or Coordinating Other Public Benefits Health Care Services Daily Living Services Personal Financial Planning Services Transportation Services Income Support Services Fiduciary and Representative Support Services Legal Services – Child Support Legal Services – Eviction Prevention Legal Services – Outstanding Fines and Penalties Legal Services – Restore/Acquire Driver’s License Legal Services – Other Child Care Housing Counseling Direct Provision of Other Public Benefits Personal Financial Planning Services Transportation Services Income Support Services Fiduciary and Representative Support Services Legal Services – Child Support Legal Services – Eviction Prevention Legal Services – Outstanding Fines and Penalties Legal Services – Restore/Acquire Driver’s License Legal Services – Other Child Care Housing Counseling (non-TFA) Supportive Services Approved by VA Financial Assistance Type Rental Assistance Utility Fee Payment Assistance Security Deposit Utility Deposit Moving Cost Transportation Services – tokens/vouchers Transportation Services – vehicle repair/maintenance Child Care General Housing Stability Assistance – emergency supplies General Housing Stability – other Emergency Housing Assistance
VA_Type_of_Service_v1_10-1-14.docx