2024 Intake Form

VA Disability Intake Form

Thanks for visiting us! We’re here to help with your VA disability case. Fill out the info below and we will contact you within 5 business days to get started with your disability case.
PLEASE NOTE!

As a non-profit organization with limited resources, we must carefully allocate our time and energy to ensure that we provide the best possible support to our clients. Therefore, we are not accepting the following cases:
- if you are currently rated at 90% (you receive $2,241.91 or more from the VA each month) and you are gainfully employed, or
- if you are currently rated at 100% (you receive $3,737.85 or more from the VA each month), or
- if you do not have a period of service under honorable conditions. For more information on upgrading your discharge status, please contact Dan Evangelista at danielevangelista9@gmail.com or at (401) 474-4764.

Contact Information

Provide some basic information so we can contact you.
Date

MonthDayYear
Date
Your Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth*

MonthDayYear
Date
Age
Gender*

MaleFemale
Social Security Number (SSN)*
VA Claim Number
*If you're not sure, this is most likely the same as your SSN, but we can fill this in later.
How did you hear about us?*
If "Other" please explain below
If "Other" - How did you hear about us?

Employment
Employment Status*
Occupation*
If you are not currently working, put your most recent job
Last Date Worked Full Time

MonthDayYear
Date
Are you unable to work full time because of your medical conditions?

YesNo
Monthly Income*
*This information is required for grants we receive to fund various programs for veterans. We will not release this information to anyone without your explicit permission.
Do you have access to reliable transportation?*

YesNo

Medical Conditions
What are your current medical conditions? List ALL current symptoms that you have talked to a doctor about that interfere with your day-to-day life.*
From your answer above, which of these medical conditions do you believe may be related to your military service?*
Have you treated anywhere outside of the VA Medical Center since you were discharged?*

YesNo
If you have treated anywhere outside of the VA since you were discharged from service, please fill out your treatment history once you submit your intake form.
If you have not told a doctor about your symptoms, our options to pursue your claims may be significantly limited. Due to the lack of medical evidence directly linking your conditions to your military service, especially considering the time since you were discharged, establishing a link to service may be extremely challenging. Ongoing medical treatment are essential to support your claims effectively.*

I have not talked to a doctor about my symptoms. I understand without a record of treatment it may be difficult to pursue my claims.
Do you have a current diagnosis of sleep apnea?*

VA Disability Intake Form