©2018-2020 All Rights Reserved Valor 4 Vet

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Person making the statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Veteran Information

 

The more information provided regarding the veteran the easier it is for the VA to identify the veteran's case.

Veteran Information

Veteran Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
Veteran Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Untitled

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Veteran Date of Birth

{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Is this the Veterans email address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Information about Individual Making the Statement

Name of Person Making Statement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Choices (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

If a choice is not selected, you will have an open space for writing. 

Mental Health Statement

{ binding firstError.message }
{ binding firstError.message }
Have you ever been hospitalized for your MENTAL HEALTH condition in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Did you have any legal or substance abuse troubles in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Are the relationships good? strained? 

Do you feel your mental health condition has been impacted by your mental health condition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Guidance Fields

Was there an accident or injury? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Has this issue become ongoing or chronic for you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Are you currently experiencing symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Did you attempt to obtain medical records regarding this matter? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

It is always advised to attempt to get medical records on your own regarding your medical conditions.

 

This also tells the VA that you attempted to get these records. 

Were you able to get medical records? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Completed Form {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Certification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

 

 

 

 

The email has been sent.

Your progress has been saved.

{ binding firstError.message }

©2018-2020 All Rights Reserved Valor 4 Vet

Veteran Account ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Folder Path {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Person making the statement: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
ip address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Veteran Information

 

The more information provided regarding the veteran the easier it is for the VA to identify the veteran's case.

Veteran Information

Veteran Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Untitled

{ binding firstError.message }
SSN {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Last 4 of SSN {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Veteran Date of Birth

Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Day of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Year of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Country Abbreviation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
Email Where Statement is to be Sent {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Is this the Veterans email address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

Information about Individual Making the Statement

Name of Person Making Statement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Choices (Optional) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }

Mental Health Statement

When were you first concerned about your mental health? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What were some of the first signs or symptoms you experienced? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Have you ever been hospitalized for your MENTAL HEALTH condition in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
When were you hospitalized for your mental health condition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Did you have any legal or substance abuse troubles in the past? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Describe your legal or substance abuse troubles: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Discuss the relationships surrounding you. Your spouse, your friends, and your family: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Do you feel your mental health condition has been impacted by your mental health condition? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Describe how your mental health condition has impacted your occupation: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Briefly discuss your current symptoms related to your mental health condition: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Briefly discuss your current treatment for the mental health condition: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }

Guidance Fields

Was there an accident or injury? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Explain the accident or injury? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
When did you first notice symptoms? Approximate Year or Time Frame. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
What symptoms did you experience in the beginning? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Has this issue become ongoing or chronic for you? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Talk about how this condition has become ongoing or chronic for you: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Provide a specific example in your life how this condition has bothered you over the months or years of symptoms: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Are you currently experiencing symptoms? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Describe your current symptoms: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
What is your relationship to the veteran? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
How long have you known the veteran? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Page 1 of Statement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Page 2 of Statement {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
Did you attempt to obtain medical records regarding this matter? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }

It is always advised to attempt to get medical records on your own regarding your medical conditions.

 

This also tells the VA that you attempted to get these records. 

Were you able to get medical records? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Completed Form {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Certification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Time {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
{binding displayValue}
{ binding firstError.message }