Connecting the Dots

This form is used for Military, Veterans, and their families looking to utilize our supports and services, such as retreats, individual sessions with The Cortina Method, food and baby pantry needs. This form also allows our case manager to assistVeterans  “connect the dots” if struggling to navigate current government systems or find additional resources that PNH does not offer. Upon completion of this form, our case manager will reach out, as soon as possible, with requested information or to schedule an initial informational session.

Date of Birth(Required)
Address
Status(Required)
Are You Disabled?(Required)
Marital Status(Required)
Is anyone over 65?(Required)
Do you have small children?(Required)
Are you employed?(Required)
Do you need assistance obtaining food?(Required)
Are you homeless or at risk of becoming homeless?(Required)
Are you struggling with PTSD, a TBI, and/or substance usage?(Required)
Are you interested in attending one of our Veteran focused retreats?(Required)