2026 VA Intake Form

VA Disability Intake Form

We are here to walk you through the process of obtaining VA disability benefits. Please complete this intake form and we will contact you via email within 1-2 business days to discuss the next steps to appoint OSDRI as your representative.
Date

YearMonthDay
Date
Your Contact Information
Your Full Name*

First NameMiddle NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
What's the best way to get in touch with you?*

Your Information (continued)
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Social Security Number (SSN)*
We use this to request access to your VA file.
VA Claim Number
*If you're not sure, this is most likely the same as your SSN, but we can fill this in later.
Marital Status*
Dependent Children*
If none, put 0
Count biological, step, or adopted children who live with you full time and are:
• Under age 18, or
• 18–23 and in school full-time, or
• Any age if they became disabled (permanently incapable of self-support) before 18.
How Did You Hear About Us?
How did you hear about us?*
If "Other" please explain below
Who referred you?*
If "Other" - How did you hear about us?*

Chemical Exposures
Do you believe you may have been exposed to any of the following hazardous materials during service?*

AsbestosDepleted UraniumRadiationJet FuelMustard GasFirefighting Foam (PFOS/PFAS)None of the AboveOther Chemical
For more information on potential exposures during service, click here.
Asbestos
For more information on how you may have been exposed to asbestos in service, visit mesothelioma.net
(Asbestos) - WHEN were you exposed to asbestos? (approximate)
(Asbestos) - WHERE were you exposed to asbestos? (name of ship, military base, aircraft, etc.)
Depleted Uranium
(Depleted Uranium) - WHEN were you exposed to depleted uranium? (approximate)
(Depleted Uranium) - WHERE were you exposed to depleted uranium? (name of ship, military base, aircraft, etc.)
Jet Fuel
(Jet Fuel) - WHEN were you exposed to radiation or high energy sources? (approximate)
(Jet Fuel) - WHERE were you exposed to radiation? (name of ship, military base, aircraft, etc.)
Mustard Gas
(Mustard Gas) - WHEN were you exposed to radiation or high energy sources? (approximate)
(Mustard Gas) - WHERE were you exposed to radiation? (name of ship, military base, aircraft, etc.)
Firefighting Foam (PFOS/PFAS)
(PFAS) - WHEN were you exposed to radiation or high energy sources? (approximate)
(PFAS) - WHERE were you exposed to radiation? (name of ship, military base, aircraft, etc.)
Radiation
(Radiation) - WHEN were you exposed to radiation or high energy sources? (approximate)
(Radiation) - WHERE were you exposed to radiation? (name of ship, military base, aircraft, etc.)
MOS: Other Exposure
(Other) Were you exposed to any other chemicals, fuels, or fumes in service? (For example: cleaning solvents, paint, sewage, pesticides, etc.) Please list them.*
(Other) WHEN were you exposed to each hazardous material noted above? (best estimate)*
If you checked None of the Above, type N/A
(Other) - WHERE were you exposed to each of these chemicals? (name of ship, military base, aircraft, etc.)*

Your Current Benefits
Are you currently receiving or have you received any of the following? Select all that apply.*

VA Disability CompensationSupplemental Security Income (SSI – income-based disability benefit)Social Security Disability Insurance (SSDI – based on work history)Military Retirement Pay (20+ years of service)Separation or Severance Pay (lump sum upon discharge)VA Pension (needs-based income benefit, not VA disability pay)NONE OF THE ABOVE
Have you filed a claim for VA disability compensation before?*
When did you last receive a decision from the VA?*
Are you currently receiving money from the VA each month?*
List EACH condition or symptom you experience today. If you are already receiving disability compensation for the condition, please note what the VA has rated you for the condition. If the condition is not linked to service yet, please note how the condition is related to your military service (injury, over time, due to another condition, due to a toxic exposure in service). *
We can verify this info once we have access to your case.
How much do you receive from the VA each month?*
What is your combined rating?*

How Are Your Current Symptoms Related to Service?
To get VA disability benefits, at least one of your medical conditions must be connected to your military service.This means:• It started while you were in the military, OR• It was caused by something that happened in service, OR• Service made a pre-existing condition worse.*

I believe I HAVE AT LEAST ONE condition or symptom from service that still affects me today.I DO NOT HAVE at least one condition or symptom from service that still affects me today.
Do you have a current diagnosis of sleep apnea?*
Why Do We Ask This? Sleep apnea is a common condition we can often link to military service, even if you didn't have symptoms in service. If you have other service-connected conditions, we can often link sleep apnea to one or more of those conditions to increase your overall combined rating.
Which conditions or symptoms affect your life the MOST today?*
This question will help us tailor our strategy to ensure your claim focuses on the conditions that have the biggest impact on your daily life.

Your Current Symptoms
Have you talked to a doctor about your symptoms?*
If you haven’t talked to a doctor about your symptoms, it will be harder to link your symptoms to service. Medical records can be used to trace your symptoms from when you were in service through today.*

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.
Have you received any medical treatment outside of the VA (ie. private doctor or hospital)?*
Please list ALL doctors or medical facilities you have been to since you were discharged:*
Medications
Are you currently taking any medications?*
Please list ALL medications you are currently taking:

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

MonthDayYear
Date
Do your medical conditions keep you from working full-time (about 40 hours per week) in any job?*

YesNo
Do you have access to reliable transportation?*

YesNo

Any Additional Information
Upload any additional information relevant to your VA disability case. (optional)

Cancelof
Is there any additional information you would like to provide?

PLEASE READ!!

Here are the few things we need you to agree to before we can enter into representation in your case
I agree that OSDRI can contact me about my case through email and text messages. If I ever want to stop receiving these messages, I can let OSDRI know in writing.*

I CONSENT TO RECEIVING TEXT MESSAGES AND EMAILS ABOUT MY CASE FROM OSDRI
OSDRI provides free legal help for new VA disability claims you haven’t filed before. If we help you reopen or appeal a claim and win, the VA will send 20% of your back pay (retroactive benefits) to OSDRI as our attorney fee. You will receive the remaining 80% directly from the VA.*

I understand that OSDRI helps with new claims for free. If my appeal or reopened claim is granted, the VA will withhold 20% of my back pay to OSDRI for legal services provided.
I understand that trying to contact the VA or file new claims on my own while OSDRI is representing me can cause delays or confusion. If I want to file something new, I’ll talk to my representative first and let OSDRI handle all filings to the VA.*

I WILL NOT FILE CLAIMS ON MY OWN WHILE I AM REPRESENTED
To proceed, please type "I WILL NOT FILE CLAIMS ON MY OWN"*
I WILL NOT FILE CLAIMS ON MY OWN
Should be Empty:

VA Disability Intake Form

Your Contact Information

Your Information (continued)

How Did You Hear About Us?

Special Circumstances

Your Time in Service

Second Period of Service

Third Period of Service

Combat Service

Your MOS Duties

MOS: Physical

MOS: Administrative

MOS: Fuels

Noise Exposure

Presumptive Exposures

Agent Orange

Burn Pits

Camp Lejeune

Chemical Exposures

Asbestos

Depleted Uranium

Jet Fuel

Mustard Gas

Firefighting Foam (PFOS/PFAS)

Radiation

MOS: Other Exposure

Your Current Benefits

How Are Your Current Symptoms Related to Service?

Your Current Symptoms

Medications

Employment

Any Additional Information

PLEASE READ!!