Veterans Expungment Clinic Information Form

Veterans Expungment Clinic Information Form

Please complete and submit this brief form to receive additional details on attending the Veterans Expungement Clinic on Thursday, February 26, 2026, from 5:30pm to 8:30pm at the Morning Star Community Center, 2525 E. 27th Street, Kansas City, Missouri.
Today's date

MonthDayYear
Date
A. IDENTIFICATION
Full Name*

First NameLast Name
E-mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
May we send you a message?*

YesNo
May we leave a message?*

YesNo
May we send a text?*

YesNo
May we leave a message?*

YesNo
How did you hear about STOP 22?*
Please list veteran services that you would find helpful in your life:
B. MILITARY SERVICE

*** NEED NOT BE HONONRABLY DISCHARGED TO ATTEND CLINIC ***

Which Branch(es) of Service did you serve?

Rows	From	To	Discharge Status
Navy
Army
Marine Corps
Air Force
Space Force

If you have received an "Other-than-Honorable" discharge designation, would you be interested in being contacted to learn more about discharge upgrades?

YesNo
C. Health & Mental Health Information

*** This Section is COMPLETELY VOLUNTARY and NOT REQUIRED *** Information provided will be used to assist STOP 22's mission of reducing veteran suicide. All information provided is private, confidential and not shared with any third-parties.
Is there a history of physical or emotional trauma that you've experienced?
How would you rate your current physical health?

PoorUnsatisfactorySatisfactoryGoodVery Good
How would you rate your current sleeping habits?

PoorUnsatisfactorySatisfactoryGoodVery Good
How many times per week do you generally exercise?
Do you have adequate access to food?

YesNo
Please list any difficulties you experience with your appetite or eating patterns.
Are you currently experiencing overwhelming sadness, grief, or depression?

YesNo
Are you currently experiencing anxiety, panic attacks, or have any phobias?

YesNo
Are you currently experiencing chronic pain?

YesNo
Do you drink more than once per week?

YesNo
How often do you engage in recreational drug use?

DailyWeeklyMonthlyInfrequentlyNever
***DISCLOSURES***

Completing this information form does not create an attorney-client relationship and it does not mean you will receive services from STOP 22.

You must have a phone number and email address that is safe for you to receive communications from STOP 22.

After sumbitting this online information form, you will recieve a follow-up email or text from STOP 22 to collect additional confidential information about you prior to the Veterans Expungement Clinic on Thursday, February 26, 2026, between 5:30pm and 8:30pm, at the Morning Star Community Center, 2525 E 27th Street, Kansas City, Missouri.
Should be Empty:

Veterans Expungment Clinic Information Form

A. IDENTIFICATION

B. MILITARY SERVICE

C. Health & Mental Health Information