Intake Sheet

Fill out this form to be contacted regarding discharge upgrade legal assistance. 

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* 1. Full Name

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* 2. Phone Number

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* 3. E-mail Address

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* 4. Mailing Address

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* 5. Branch of Service

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* 6. When did you serve?

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* 7. Type of Discharge

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* 8. Reason for Separation

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* 9. Have you applied for a discharge upgrade before?

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* 10. Are you diagnosed with a mental health condition?

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* 11. If yes, what are your diagnoses?

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* 12. If diagnosed, is your mental health condition service-connected by the VA?

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* 13. Did you suffer an incident of military sexual trauma?

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* 14. How did you hear about the program?

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* 15. Additional comments?

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* 16. File Upload

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File

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