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Denver Regional Vets Intake Form

  1. Contact requested by: required
  2. Name of individual who needs services: required
  3. Phone: required
  4. Email: required
  5. Preferred method of contact: required
  6. Where is the Veteran Currently Living? Please include City & County.
  7. What branch of service is/was the Veteran in? What component? (NG/RES/AD)
  8. Is the individual seeking assistance a family member of the Veteran?
  9. If yes, is the Veteran deceased?
  10. What is/was the Veteran's date(s) of service? (Start and End Dates)
  11. Did the Veteran deploy? If so, how many times?
  12. What are the date(s) and location(s) of their deployment(s)?
  13. Is the Veteran currently receiving VA benefits?
  14. Has the Veteran applied for benefits?
  15. What community resources has the Veteran utilized, if any?
  16. What is the Veteran's discharge status?
  17. Does this Veteran have any dependents? If so please list them.
  18. What is the deadline for services needed?
  19. Do I have permission to share this situation with fellow community resources?
  20. Does the veteran have a copy of their DD214 if it is needed?

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