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Veteran's Intake Form

WELCOME TO H.E.L.P

Where we believe in empowering our veterans with the support they deserve. To facilitate your counseling experience, we kindly request that you fill out our veterans intake form below. This comprehensive form will help us assess your individual situation and enable us to provide the best possible guidance and resources. Your sacrifices are invaluable, and we are committed to helping you find the assistance you need. Take the first step today by submitting the form.

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Client Information

Birthday
Month
Day
Year
Gender
Male
Female
Non Binary
Other

Include City, State and Zip Code

Preferred Method of Contact
Phone
Email
Text

Military Service

Dates of Service (Start)
Month
Day
Year
Dates of Service (End)
Month
Day
Year
Discharge Status
Honorable
General
Other
VA Claim Status
Approved
Pending
No Filed
Are you connected to a VA provider?
Yes
No

Counseling Needs & History

Have you previously received counseling or mental health services?
Yes
No
Are you currently taking any medications for mental health?
Yes
No
Check any concerns you would like to address (Check all that apply)

Functioning & Support

Are you currently employed?
Yes
No
Living Situation
Do you have a support system?
Yes
No

Scheduling Preferences

Preferred Days
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time
Morning
Afternoon
Evening
Do you prefer
In-Person Counseling
Virtual Counseling

Consent & Signature

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