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Your Name(*)
Please let us know your name.
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Your Email(*)
Please let us know your email address.
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Phone (###-###-####)
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Previous Submitted Mental Health Claim
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Service Details
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Branch(es) of Service(*)
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Please specify your dates of service.
If your service dates are too complicated to define here (multiple branches, full time followed by active reserve duty, etc. please explain in "additional notes" field below.
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Date Entered(*)
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Date you entered the military
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Date Discharged(*)
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Date you discharged from the military
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Discharge Type(*)
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Stressor Details
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Stressor Experience
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Is stressor documented by records?
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Your stressor (above) must be something you can document with 1) military medical or personnel records; OR 2) news clippings; OR 3) lay statements (letter(s) from family member or friend that corroborates your account of events)
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Incident Occurred Between(*)
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and This Date(*)
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Base/Location During Incident(*)
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Unit Assignment(*)
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With what unit did you serve?
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MOS(*)
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Specify your MOS (your job and its associated MOS code)
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Briefly Describe Incident
Please let us know your message.
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