ValorFit® Veteran Application for Eligibility

Due to high-volume, please expect up to 7 business days for standard application review. Only high-risk, eligible Veterans will be considered for more expedient timing during this period. If you are approved for Program entry, we will reach out to you to communicate your status and any next steps.

Please note: If you have already completed the ValorFit Program - all, or in part - we appreciate your renewed inteterest, but are unable to satisfy your request for reentry at this time.

Thank YOU again for your interest in ValorFit and we are grateful for your Service. We are Stronger Together.
Welcome - Tell us about yourself.

Note: All required fields & documentation must be completed for consideration. Please allow 5-7 business days from submission of your completed application for us to determine your eligibility and placement. ValorFit® will contact you directly with your application disposition. Thank you for your interest in ValorFit®. We are Stronger Together.
Full name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Currently Married*
Children*
Veteran Status*

YesNo
Active Duty Branch Served*
If not Active Duty Veteran, what Component best describes you?*
Veteran Discharge Disposition*

HonorableGeneralDishonorable
If you have a DD214 from Active Duty service, but are now currently serving in the National Guard or Reserve, are you eligible for VA Healthcare Benefits?*

YesNoNot sure
If you are currently Reserve or Guard, please work with your chain of command or leadership to provide a Letter of Authorization or Letter of Acknowledgement from your leadership to ValorFit®. This letter is required to contain the following information:
- Your name, rank, unit, and MOS/job classification
- Your current PT test score
- Any permanent or temporary profile information
- Your reason for application to ValorFit® for program resources
- Your leadership name, rank, contact information
- Signed/dated by your company or unit leadership
Only letters that meet these requirements will be considered for application.
Please submit a copy of your Form DD214

Browse Files

Cancelof
Health & Wellness - Tell us more.
We can all help prevent suicide. The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones.

The National Suicide Prevention Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week.

Anyone can struggle with suicide. If you are, Help is waiting.

800-273-TALK (8255)
Your health & wellness matters to ValorFit®, and we want to know more about how you're feeling, where you may be struggling, and how you want us to help. Please complete each section of this intake below and be honest with your answers. If we need more information, we will contact you directly.
Do you have a Service-Connected Disability rating?*

YesNoYes, but pending

Physical Well-Being: How do you feel?

	1	2	3	4	5

1 is Miserable, 5 is Great

Mental/Emotional Well-Being: How do you feel?

	1	2	3	4	5

1 is Miserable, 5 is Great

Life: How is it to live your Day to Day Life?

	1	2	3	4	5

1 is Miserable, 5 is Great

If yes, what percentage (%) is your Disability rating?
Do you have proof of your Service-Connected Disability? If so, please submit.

Browse Files

Cancelof
If you do NOT have poof of your Service-Connected Disability rating, why not?
PTSD - Have you been diagnosed with or treated for PTSD?*

YesNo
MST - Have you been diagnosed with or treated for MST*

YesNo
Tell us how ValorFit® can help?

Tell us where you need support & help in your life - there is courage in honesty. Please mark all that apply.
Which areas do you need support for your daily life?*

DepressionAnxietySleepFitnessWeight ManagementWellnessRecoveryStrucutre & Routine
What do you hope the ValorFit® Program will help you to accomplish?*

Establish a productive routineHelp you regain a sense of structureGet into better physical conditionReduce or manage pain & achesSense of belongingImproved sleep & restQuality of LifeMore happiness & mood stabilityIncreased sense of purposeBuild & establish a network
Your Words. Tell us why ValorFit®? (This is a required section. Use your own words & tell us as much as you'd like. We want to hear from you - we are listening.)*
I have read, understood, and completed this application for ValorFit® consideration & placement. I acknowledge that all questions were answered honestly and to my full satisfaction, and for the sole purpose of being considered for application and placement into the ValorFit® Program.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Welcome - Tell us about yourself.

Health & Wellness - Tell us more.

Tell us how ValorFit® can help?