VA Military Intake Form "*" indicates required fields Your InformationFirst Name*Middle NameLast Name*Branch of Service*SelectAir ForceArmyNavyMarinesCoast GuardSpace ForceDate of Military Service:*Enlistment date: Month Day Year Discharge date: Month Day Year Active Duty Deployment:*Number of times*From Dates:*Approximate Month Day Year To Dates:*Approximate Month Day Year Places:*Bases Served Stateside:Base 1Base 2Base 2Base 3Base 3Base 4Base 4Base 5Base 5Are 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 PhoneThis field is for validation purposes and should be left unchanged. Δ
