Boston VA Healthcare System

Medical Legal Partnership Referral Form

Any provider within the Boston VA Healthcare system may complete the form below to refer individuals to Veterans Legal Services (VLS) for legal assistance. Please note: the referral will be used to screen the Veteran for initial eligibility for services and does not guarantee that VLS will be able to provide legal representation. A VLS advocate will review the referral information and contact the Veteran directly to either schedule the Veteran for an initial meeting at the next available legal clinic on the Brockton VAMC campus, or provide other appropriate resource information if the Veteran is not eligible for VLS's services.

This program is made possible in part by funding from the Bob Woodruff Foundation, which is dedicated to ensuring that our nation's veterans, service members and their families - those who stood for us - have stable and successful futures.

For the VA Employee Completing this form

Today's Date

Name of the person completing this form

Title

Email address

Phone number

For the Veteran you want to refer for legal services

Has the person you are referring to VLS served in the US military, including National Guard or Reserves? Please note: Discharge status is not relevant to VLS's determination of eligibility for services.

Has the Veteran signed a VA Release of Information to allow VA staff to share information about the Veteran's situation with VLS?

First name

Last name

Email address

Veteran's phone number

Is it safe for us to call the Veteran? Is it safe to leave a voicemail at this number?

Is the Veteran currently in-patient at the VA?

Does the Veteran live in Massachusetts? [VLS's services are limited to Veterans in Massachusetts. If the Veteran is in a residential program in Massachusetts VLS would consider them as living in Massachusetts]

What state do they live in?

Additional information about the Veteran's situation

What type of legal problem does the Veteran need help with? [Please note that VLS does not accept criminal cases, Sex Offender Registry Board (SORB) matters, or Department of Children and Families (DCF) matters]

Briefly (2 or 3 sentences) describe the legal issue.

Is the legal issue a Massachusetts case?

Are there any upcoming deadlines related to the Veteran's legal issue? If so, please tell us what and when. For example, "the Veteran needs to file a notice of appeal by September 30, 2021." Note: the Veteran should NOT allow any deadlines to expire while waiting to meet with VLS.

Does the Veteran have paperwork related to their issue like a benefits denial letter, debt collection notice, Notice to Quit, or Court documents? If possible, please fax any relevant paperwork to our office at 844-621-2797 or email it to info@veteranslegalservices.org. Please redact any sensitive information, such as Social Security numbers or bank account information, before sending paperwork to VLS.

Please enter the Veteran's total approximate monthly income from all sources (if you know it). Please include VA benefits, Chapter 115, Social Security and other forms of income even if they are not taxable or countable for other purposes.

Does anyone else live with the Veteran that is not a roommate?

How many other people live with them? (Do not count roommates)

Who else lives with the Veteran/what is their relationship? For example, spouse, child, significant other, etc. Please list all household members.

Please enter the total approximate monthly income from all sources of any other adults in the veteran's household (if you know it). Please include VA benefits, Chapter 115, Social Security and other forms of income even if they are not taxable or countable for other purposes. Do not include income of roommates.

Do the Veteran pay support for anyone who does not live with them or who only lives with them sometimes? For example, child support or alimony.

How many people do they pay to support?

How much do they pay per month in support? (Estimate if necessary)

Income Eligibility

Household size for VLS purposes (this field is calculated automatically based on the responses above and may be different from how other programs define household).

Total Monthly Household Income for VLS purposes (this field is calculated automatically based on the responses above and may be different from how other programs define household income).

Other

Is there anything else that the VLS advocate should know about the Veteran's situation?

Questions? Contact us at 857-317-4474 or info@veteranslegalservices.org

Veterans Legal Services, P.O. Box 8457, Boston, MA 02114. Phone: 857-317-4474