Intake Sheet

Fill out this form to be contacted regarding discharge upgrade legal assistance.  Our response time is typically 14 business days. Please note that submitting this form is not a guarantee of legal representation.

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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. What is the best way to reach you?

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* 6. Branch of Service

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* 7. When did you serve?

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* 8. Type of Discharge

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* 9. Reason for Separation

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

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

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* 12. If yes, what are your diagnoses?

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

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

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* 15. How did you hear about the program?

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* 16. Additional comments?

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* 17. File Upload

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

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* 18. Optional: Which race/ethnicity best describes you? (Please choose only one.)

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* 19. What is your gender?

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