Evaluations are free. Provide as much information as you’re comfortable with; it is not necessary to fill in every blank. However, more information should yield a more thorough evaluation. If you have a survivor’s benefits claim, please answer with the Veteran’s information and provide details in the comments section. Please allow at least one week for a response. If you have an urgent deadline, please be sure to mention that in the form.

    How did you hear about me?

    Military Service:

    Service Dates:

    Type of Discharge:

    Are you receiving military retirement?

    Current VA Rating (if any):

    If you are unsure of your rating, how much do you receive from the VA each month?

    *

    Are you receiving income-based non-service-connected VA pension?

    *

    Do you have a VA decision that is appealable or already on appeal?

    *

    If so, please note the following:

    Type:

    Date on cover letter of decision (if known):

    *

    General Issues (check all that apply):

    Specific Issues (please provide details):

    Date of appeal (if any):

    *

    Employment Status:

    *

    If you are unable to work, are you receiving Social Security disability benefits?

    If you are already service-connected for any disabilities, please list each condition and its corresponding rating if known (even if some are rated at 0%).

    *

    Do you have any other VA claims or appeals pending?

    If so, describe:

    COMMENTS, QUESTIONS, ADDITIONAL INFORMATION:

    Attach any relevant documents below
    (File size limit is 25 MB. Acceptable file types include: pdf, doc, docx, and jpg.)

    If uploading is not available, please fax it to me at (210) 817-8695. If you prefer to mail documents for review, please send copies only as originals cannot be returned.