CivGATE
LA County Department of Military & Veterans Affairs — Governed AI Intake Tool
IGM GOVERNED
USPTO 19/571,156
Courthouse
Select Location
CCB — Clara Shortridge Foltz
Van Nuys Courthouse
Compton Courthouse
Lancaster Courthouse
Date
VSR
Visit Type
Select
Initial Contact
Follow-Up
Court Appearance
Benefits Inquiry
Crisis Intervention
Records Request
Diversion Program
CONTACT STATUS
New / Returning
New Contact
Previously Served
▪ Personal Information
▼
Last Name *
First Name *
Middle
Suffix
Jr.
Sr.
II
III
IV
Esq.
Archived
SSN *
File #
EDIPI/ICN#
Creation Date
Rep
Referred By
Walk In
Veterans Court
Probation
Parole
Public Defender
Defense Attorney
DA Office
Family / Friend
VA Referral
Other Agency
Self-Referral
Other
Auditable Aid Code
Other Aid Code
MC-05m
CW-5m
Other
Preferred Contact Method
Text
Call
Email
Mail
In-Person
AKA
Sex
Male
Female
Other
Decline to State
Insurance #
Current Gender
Male
Female
Non-Binary
Transgender Man
Transgender Woman
Genderqueer
Decline to State
Sex At Birth
Male
Female
Intersex
Decline to State
Race / Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Pacific Islander
White or Caucasian
Two or More Races
Other
Decline to State
Marital Status
Single
Married
Domestic Partner
Separated
Divorced
Widowed
Dependents / Children
Sexual Orientation
Straight / Heterosexual
Gay
Lesbian
Bisexual
Queer
Asexual
Decline to State
Born *
Primary Language
English
Spanish
Armenian
Tagalog
Korean
Vietnamese
Mandarin
Cantonese
Farsi
Russian
Arabic
Other
Contact Person
BirthPlace
Regional Office
344 — Los Angeles
301 — Philadelphia
310 — Waco
320 — San Diego
321 — San Francisco
350 — Reno
Other
Died
Deceased
Driver License #
Issuing State
DeathPlace
POA
CDVA
DAV
VFW
American Legion
AMVETS
PVA
VVA
MOPH
Other
Other POA Description
NSC Rating
SC Rating
Permanent & Total
Internal File Location
Electronic File
Hard Copy
▪ Address
▼
Address 2 (Street)
Address 3 (Apt / Unit / Suite)
City
State
ZipCode
County
Phone
Ext.
Phone 2
Fax
eMail
Emergency Contact
First Name
Last Name
Phone #
Relation
Spouse
Partner
Parent
Sibling
Child
Friend
Case Manager
Attorney
Other
▪ Period of Service
▼
Branch
Entered
Released
Service #
Verified
Officer
Rank
ERA
Discharged
▪ Status Flags
▼
⚠ ALERT — Hostile:
0
1
2
3
4
5
0 = No Alert / 5 = High Risk
Housing Status
Housed
Unhoused / Homeless
Transitional Housing
Shelter
Couch Surfing
At Risk of Homelessness
Unknown
Homeless
Retiree
Van Rider
Pension
Incarcerated
Judged Incompetent
Conserved
MediCal
DIC
A & A
Compensation
Parolee
'5150'
Diversion (1001.8)
Veterans Court (1170.9)
▪ VTC / Legal
▼
Case #
Next Court Date
Private Attorney
Public Defender
Other
Component
Active Duty
National Guard
Reserve
Reserve Type
Combat Veteran
Yes
No
Combat Zone
MST Survivor
Yes
No
Prefer not to say
Veteran Status Confirmed
Yes
No
Pending
SC Disability
Yes
No
Unknown
VJO Specialist
Current VA Rating %
Unknown
▪ Service Needs
▼
Interested in Services?
Yes
No
Filed VA Disability Claim?
Yes
No
Unknown
Check all that apply
VA Benefits / Claims
Housing Assistance
Mental Health Services
VA Medical
Employment / Education
Substance Use Treatment
Transportation
Community Service Referral
Legal Services
VPAN Referral
Reentry / Release Planning
Discharge Upgrade
CVJP Referral
Other
Other — Specify
▪ Healthcare
▼
VA Enrolled
Medi-Cal
Private / Other
Private / Other — Specify
▪ Treatment & Forms
▼
Referred to Treatment?
Yes
No
Treatment Location
Type of Referral
Substance Abuse
Mental Health
Dual Diagnosis
Medical
Housing
Employment
Other
Method of Treatment
In-Patient
Out-Patient
Telehealth
Residential
Forms Required
Forms Submitted
▪ Notes
▼
Comment
VETPRO TRANSFER SHEET — Keep this open while entering into VetPro
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