Intake form

Name *

Address, City, State, Zip

Phone number

Email address *

What is your preferred method of communication?

What type of service are you seeking?

Please select at least one option.

Increases

Review of Decision

Appeal

Discharge upgrades

Severance of service connection

Disability of children

Fee disputes

Wrongful withholding of compensation

Pending Claims

Overpayment and waiver

Medical malpractice/VA Negligence

Wrongful death/Death Indemnity Compensation (DIC)

Special Monthly Compensation/Aid &. Attendance

What is your current disability claim status?

Please select at least one option.

I have denials

I recently filed a claim

I want an increase

I am worried that I did not get the right amount of backpay.

I have a claim on appeal right now

What branch of the military did you serve?

What is the nature of your discharge?

Please select at least one option.

Honorable

General Under Honorable Conditions

Other Than Honorable

Bad Conduct

Dishonorable

Uncharacterized (often Entry-Level Separation)

Medically Discharged

Did you serve in the Reserves or National Guard?

In layman's terms, describe your job in the military in 2-3 sentences.

What is your current disability claim overall percentage and what is the percent rating for each item for which you are rated?

Have you previously worked with an attorney on any of these matters?

What did you go to the doctor/medic/chaplain/corpsman for while in the military?

Did your job in the military involve any of the following:

Please select at least one option.

Climbing ladder wells

Police work

Firefighter work

Ship maintenance

Combat

Flying aircraft

Jumping from aircraft

Medical, morgue or any conduct involving deceased servicepersons or their families

Chaplain or Chaplain's Assstant

Heavy lifting

Contorting your body into tight spaces

Were you exposed to any of the following:

Please select at least one option.

Burn pits

Oil Fileds

Agent Orange

Camp Lejeune water

Fort McClellan chemicals

Toxic chemicals

Excessive noise

IED, explosives, excessive gun fire

Mental Health - Which of the following apply to you?

Please select at least one option.

I have a mental health diagnosis of anxiety, depression and/or PSD.

I have been hospitalized for my mental situation

I have/had suicidal ideations

I have seen/am seeing a therapist, counselor or pastor

I have/had a drug or alcohol problem

I am taking prescription medication for my mental situation

Mentally, the worst thing that happened to me in the military was when...

Which of the following are you having trouble with?

Please select at least one option.

Insomnia

GERD/Acid Reflux

Headaches

Sleep Apnea

Feet

Ankles

Legs/Shins

Knees

Back

Hips

Shoulders

Elbows, Hands, Fingers

Neck

Breathing, allergies, sinuses

Erectile dysfunction

Chronic fatigue

Anxiety, depression, PTSD

Heart

Who referred you to us?

Please select at least one option.

Lanette Dunlop

Vange

Frankie Dillard

Veteran Wealth Partners

Venus Elfatin El

Jordan Stovall

Antwon Dukes

Tacuma Jawara

Kia Langford

Alexander Perez

Victor Betts

Additional questions or comments