START THE PROCESS: ASSISTING VETERANS WITH THE VA DISABILITY RATING PROCESS Name * First Name Last Name Date of Birth * MM DD YYYY Phone (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Social Security (Number or VA File Number) * Military Service Branch * Service Dates (Start and End) * MM DD YYYY Primary Disability * Secondary Disabilities (if applicable) Date of Diagnosis * MM DD YYYY Description of Symptoms and Impact on Daily Impact * Rank at Time of Discharge * Type of Discharge (Honorable, Other than Honorable, etc.) * Any combat-related service Deployment Locations and Dates (if applicable) Ongoing Treatment or Medical Care (including physician contact details) * Current Medications Current Therapies or Rehabilitation Previous Claims Submitted to the VA (dates and status) * MM DD YYYY Last Job Held Before Disability (if applicable) * Impact of Disability on Employment Type of Assistance Needed (e.g., financial aid, healthcare, housing, employment support) * Any accommodations or specific needs Consent for Release of Medical and Service Records * Yes No Acknowledgment of the VA’s review process * Signature and Date Thank you for completing the form! we'll be in touch soon to assist you with the VA Disability Rating Process.
