Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Race
*
Please Select
White
African American
American Indian
Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Prefer not to Disclose
Gender
*
Please Select
Male
Female
Other
Prefer not to Disclose
Please enter your gender
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Please select which one best describes you:
*
Please Select
I am the Veteran or Service Member
I am a Family Member or friend of a veteran / service member
BRANCH OF SERVICE
*
Please Select
ARMY
AIR FORCE
COAST GUARD
NAVY
MARINES
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Do you have a veteran in your life who you believe could benefit from additional resources or assistance, such as VA Health Care or Benefits, mental health support, housing, or job placement etc?
*
Yes
No
Please provide a brief explanation below. We respect your privacy, and any information shared will be used for follow-up purposes only, to offer the necessary support. Thank you for helping us ensure our veterans receive the help they need.
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Are you in need of assistance with VA Health Care or VA Benefits?
*
Yes
No
Your well-being is important to us. Please select the option that best represents your current situation:
*
Feeling great, no concerns at the moment.
Dealing with occasional stress but managing well.
Struggling with some challenges and could use some support.
Experiencing significant distress and could use immediate assistance.
Are you in need of any other resources such as housing assistance, utilities, job placement etc.?
*
Yes
No
If you have any specific needs you'd like to tell us about, briefly list them here. We respect your privacy, and any information shared will be used for follow-up purposes only, to offer the necessary support.
mental health, housing needs, legal, etc.
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I understand that someone from the Fox Program Care Team will check in with me via phone call or text message. Please be assured that any information provided regarding a veteran's need for additional resources or assistance will be kept confidential. Your privacy is important to us, and the details you share will only be used for follow-up purposes, ensuring the veterans in our community receive the support they require. Thank you for your understanding and cooperation.
*
I understand
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