CLIENT INTAKE FORM

Today's Date:

CLIENT INFORMATION

Your Full Name (including full middle name):

Home Address:

State:

City:

Zip Code:

Home Phone number:‍‍‍‍‍‍‍‍‍‍‍‍

Cell Number:

Email Address:

Your Soc. Sec. No:

Date & City/State of Birth:

Other names you have been known by:

Name of additional Point of Contact (spouse/family member/friend, etc.):

Additional Point of Contact Phone Number:

Additional Point of Contact Email:

What is your current overall VA rating %:

Which VA Medical Center (City & State) has your medical records?

Do you have multiple claims pending?

If so, how many?

Pending Claim #1: What was the VA Decision date(s)?

What % were you granted?

Have you filed a Notice of Disagreement, Higher Level Review or Supplemental Claim?

If so, what date?

Pending Claim #2: What was the VA Decision date(s)?

What % were you granted?

Have you filed a Notice of Disagreement, Higher Level Review or Supplemental Claim?

If so, what date?

Are you now, or have you been represented by another Attorney or Veteran Service Organization (TVC, DAV, VFW) on this claim or any other VA claim?

If so, who and when?

VA Disabilities issues you are wanting us to appeal:

What doctors and medical facilities have you received care for the VA medical issues you have claimed and when?

Are you currently working?

If you are not working or not looking for work, are you unable to work because of the disabilities you have claimed?

If so, which disabilities?

Are you receiving Social Security Disability Insurance (SSDI)? If yes, for how long and for what disabilities?

If not receiving SSDI, are you interested in speaking with an Attorney about SSDI?

Current Employer:

Position/Type of work:

Did you undergo a medical separation board or medical retirement board by the military? If so, when and where?

Did you receive medical separation pay from the military? YES/NO If so, what amount?

Do you have any debts outstanding with the VA or owe any government agency money for any overpayment of benefits?  YES/NO  If yes, for what amount?

Branch of Service:

Active Duty Service Dates:

Reserve / National Guard Service Dates:

MOS: (numerical & job name)

Rank:

Were you Airborne qualified?

How many jumps did you do in your career?

Did you retire from Active Duty, Reserve or Nat Guard? If so, which and when?

Did you retire from Active Duty, Reserve or Nat Guard? If so, which and when?

What type of discharge did you receive (Honorable, General, OTH, Bad Conduct or Dishonorable)?

Are you currently in the Reserves or National Guard? If so, which?

Have you served in:

Dates & Location of Deployments:

Deployment Unit(s):

Did you receive any of the Combat Medals below:  

Medal:

Additional Comments:

How did you hear about our office?