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Service Member Information
Which area are you closest to? Choose National Virtual if you are not located in a state with an existing chapter.
Please select...
Southern California
Northern California
Houston, TX
San Antonio, TX
Colorado Springs, CO
Jacksonville, NC
Ft. Campbell (KY/TN)
National Virtual Chapter
South Eastern Florida, Port St. Lucie Area
Fayetteville, NC
Tampa Bay Area, FL
DC-MD-VA (DMV Area)
Service Member First Name
Service Member Last Name
Service Member Email
Mobile Phone
Mailing Street
Mailing City
Mailing State/Province
Mailing Zip/Postal Code
Home state of domicile, if different from above:
Type N/A if Mailing State and Home State are the same
Service Member Status
Please select...
Active Duty
Veteran
Retired
Service Member Disability (Check all that apply)
PTSD
Mental Health
TBI (Traumatic Brain Injury)
Amputee
SCI (Spinal Cord Injury)
Hearing loss
Memory loss
Vision Loss
Mobility
Cancer
Other terminal illness
Other
Veteran's Disability Rating
Please select...
Active Duty N/A
Rated 60% or less
70%
80%
90%
100%
Is the veteran's rating permanent & total?
Please select...
Yes
No
Where does service member receive care?
Branch of Service:
Please select...
Army
Navy
Coast Guard
Marine Corps
Air Force
Space Force
Highest Achieved Rank
Year exited military:
Marital Status:
Please select...
Married
Separated
Divorced
Single
Does the veteran currently have a caregiver or other support person living in the home? *
If the Veteran is Married and the Caregiver is the Spouse, select No for this question. The Spouse information is all that is needed in that case.
Please select...
Yes
No
Spouse Information
Spouse First Name
Spouse Last Name
Spouse Email
Spouse Phone Number
Spouse Mailing Street
Spouse Mailing City
Spouse Mailing State
Spouse Mailing Zip Code
Did spouse serve in the military?
Please select...
Yes
No
Currently enrolled VA caregiver program
Please select...
Yes
No
Caregiver Information
Caregiver First Name
Caregiver Last Name
Caregiver Email
Caregiver Phone Number
Caregiver Mailing Street
Caregiver Mailing City
Caregiver Mailing State
Caregiver Mailing Zip Code
Did caregiver serve in the military?
Please select...
Yes
No
Currently enrolled VA caregiver program
Please select...
Yes
No
VA Disability Award letter with rating percentage, proof of Med Board, proof of assignment to Walter Reed Medical Center or another military medical center or military unit assignment for medical purposes
Proof of post 9/11 service (DD214, VA award letter showing dates of service, ect)
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The collected demographic information is voluntary and used for research and reporting purposes only. Your responses will not impact any of the services you receive. If you prefer not to answer, simply leave the question blank.
Veteran Demographic Information
Year of Birth
Race
Please select...
White
Black or African American
American Indian or Alaska Native
Asian and Native Hawaiian or Other Pacific Islander
Multiple Categories
Ethnicity
Please select...
Hispanic or Latino
Non-Hispanic or Latino
Ethnicity Unknown
Highest level of education in your household:
Please select...
GED
High School Diploma
Some College
Associates degree
Bachelor's degree
Graduate level degree
Professional certificate
Veteran's highest level of education:
Please select...
GED
High School Diploma
Some College
Associates degree
Bachelor's degree
Graduate level degree
Professional certificate
Employment status:
Please select...
Full time outside of the home
Part time outside of the home
Full time remote/in home
Part time remote/in home
Not currently employed
Annual household income:
Please select...
Less than $20,999
$21,000-$49,000
$50,000-$74,999
$75,000-$89,999
$90,000 or more
How many children under the age of 18 reside in your home?
Please select...
0
1
2
3
4
5
6 or more
Spouse's Demographic Information
Year of Birth
Race
Please select...
White
Black or African American
American Indian or Alaska Native
Asian and Native Hawaiian or Other Pacific Islander
Multiple Categories
Ethnicity
Please select...
Hispanic or Latino
Non-Hispanic or Latino
Ethnicity Unknown
Spouse's highest level of education:
Please select...
GED
High School Diploma
Some College
Associates degree
Bachelor's degree
Graduate level degree
Professional certificate
Employment status:
Please select...
Full time outside of the home
Part time outside of the home
Full time remote/in home
Part time remote/in home
Not currently employed
Contact Information