LB VA Questionnaire Form

Form

Thank you for seeking support from LB Veteran’s Assistance Services. This questionnaire is designed to help me understand your needs, connect you with the right resources, and provide the most effective assistance. Your responses will be kept confidential and used solely to better serve you.
Name

PrefixFirst NameLast NameSuffix
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Branch of Service (click all that apply)
Dates of Service
Type of Discharge/Separation
Did you serve in a combat Zone?
If yes to previous question, please list locations
What was your job in the military?
Are you currently rated?
If yes to previous question, what is your current combined VA rating?
Please list rated disabilities
Do you have any pending claims?
Do you have your (service)medical record?
Are you comfortable sharing any experiences from your military service that might be relevant to the support you're seeking?
How do you prefer to receive information and support?
Do you have a login.gov or ID.Me registered account with VA.GOV?
How did you hear about LB VA Services? (Ex. Referral, social media etc.) If Referral, please indicate by whom.
* I understand that the information I provide in this questionnaire will be used to help LB VETERAN'S ASSISTANCE SERVICES understand my needs and connect me with appropriate resources and services.*
* I consent to LB VETERAN'S ASSISTANCE SERVICES contacting me using the information provided above to discuss my needs and potential support options.*
*Please be informed there is a one time $50 charge for consultation and must be paid once appointment is scheduled.*

Can be paid via cashapp $QuniaWBush or Zelle: 803-761-2613
Thank you for completing this questionnaire.

I am here to support you. Once I receive your form, I will review and be in in touch with you to schedule a one-on-one consultation.

I look forward to connecting with you.

Sincerely,

LB Veteran's Assistance Services
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