• VA Disability Intake Form

    VA Disability Intake Form

    Thanks for visiting us! We’re here to help with your VA disability case. Please complete this intake form and we will contact you via email within 3-5 business days to discuss the next steps to appoint OSDRI as your representative.

  • 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
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     / /
  • Gender*

  • Dependents

  • Marital Status*

  • Dependent Children: Biological, stepchildren, or adopted children who are unmarried and either under the age of 18, between the ages of 18 and 23 and attending school full-time, or were permanently incapable of self-support before the age of 18.

  • Special Circumstances

  • Do any of the following extreme circumstances apply to you?
  • Can you provide copies of the following? (check all that apply)

  • *In order to request priority processing of your case, we need evidence to support this request. We will put together this request to submit with the evidence you provide.

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  • Service Information

  • Are you still in the National Guard or Reserves?
  • Are you still on Active Duty?
  • Date of Entry*
     / /
  • Date of Discharge*
     / /
  • Did you serve in combat?*
  • Do you have another period of service?
  • Second Date of Entry
     / /
  • Second Date of Discharge
     / /
  • Do you have more than two periods of service?
  • Potential Exposures

    Potential Exposures

    Please answer the following questions about potential exposures to toxins while you were in service.
  • Agent Orange - Did you serve in any of the following locations?*
  • Burn Pits - Did you serve in any of the following locations?*
  • Camp Lejeune - Did you serve in any of the following locations for 30+ days? (does not need to be consecutively)*
  • Image field 100
  • Do you believe you may have been exposed to any of the following hazardous materials during service?*

  • For more information on potential exposures during service, click here. 

  • Current Benefits

  • Have you applied for disability compensation in the past?*
  • Are you currently receiving or have you received any of the following? Select all that apply.*

  • Employment

  • Last Date Worked Full Time
     / /
  • Are you unable to work full time because of your medical conditions?
  • Do you have access to reliable transportation?*

  • Medical Conditions

  • In order for us to help with your disability case, you MUST have at least ONE medical condition or set of symptoms that you believe was incurred while in active-duty military service that continues to affect you today.*
  • Have you treated anywhere outside of the VA Medical Center since you were discharged?*

  • If you have treated anywhere outside of the VA since you were discharged from service, please let us know.

    There will be a separate link to complete your treatment history once you submit this intake form. This form will also be emailed to you to complete shortly after you submit your completed intake form. 

  • Goal for Your Case

  • How can we help?*
  • When did you receive a decision from the VA?*

  • PLEASE NOTE!! This information will help us tailor our strategy to ensure we focus on the claims that have the biggest impact on your life today.

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  • Client Memorandum of Understanding

    The below Memorandum of Understanding outlines the most important principles and expectations we need you to agree to in order to provide competent and valuable representation. By completing this intake and clicking Submit, you agree to abide by each and every term of this agreement to help facilitate OSDRI's representation on your behalf.
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