VA Military Intake Form "*" indicates required fields Your InformationFirst Name*Last Name*Date of Military Service:*Enlistment date: Month Day Year Discharge date: Month Day Year Active Duty Deployment:*Are you in the Reserves?* Yes No Date of last Promotion or Demotion:* Month Day Year Reason for Promotion or Demotion:*Medical Discharge:* Yes No Reason:*Critical Incidents:* Yes No Event:*Violence while serving or outside of Military:* Yes No Event:*Thoughts of hurting self or others or Pets?* Yes No Hospitalization for mental/behavioral health?* Yes No Date:* Month Day Year Please note: I am not trained to evaluate for readiness for duty. I do not fill out military forms, I am not involved with VA requirements, I am not a part of the VA. I have no legal standing with VA, and I do not share details of our time together with the VA. VA may from time to time request an update from me. I will only share diagnosis and an overview of our time together.FYI: I am a veteran and know some of what it feels like to serve our great nation. It is very important to me that you are genuine and authentic. Please sign below that information shared above is correct to the best of your ability and you have read and understand my position as your therapist in regard to the VA.Client Signature*Today's Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ
