Consultation Request Form

Filling out the consultation form is the first step for veterans who were denied benefits or injured by VA clinicians at agency hospitals. It helps us get to know you better and cuts through some of the gray areas in a veteran’s denial or malpractice claim.

Terms of Serivce

Note that not everyone who fills out this request form will be eligible for a consultation or feedback, and submitting this form in no way creates an attorney-client relationship. *

I understand

First Name *

Last Name *

Email *

Phone *

State *

Education *

Birth Date *

Are you a veteran? *

Yes

No, my family member is.

What is your primary concern in one sentence? *

What is your secondary concern in one sentence? *

What is date on most recent denial? *

When did you file the application? *

Do you have a disability rating? *

Yes

No, but it's pending

VA Caregiver Question *

Yes, we get Caregiver benefits.

No, we do not but should/did.

No, Caregiver does not apply.

What is your total disability rating? *

What do you believe your total disability rating should be if rated fairly? *

Present Employment *

Employed

Unemployed

Present Employment Duration *

Less than 1 year

1 - 2 years

2 years or greater

Military Separation Era *

Years of Military Service *

Military Service Type *

Active Duty

Reserve

Guard

Other

Final Discharge Date *

Date of Denial *

Were you (or a loved one) injured by VA health care? *

Yes

Please select all that apply *

I was injured by a negligent VA clinician.

I was injured by a wrong prescription or lack of prescription.

I was harmed by a lack of health care.

My condition was not diagnosed properly or timely.

Other

When did you learn you were first injured? *

Legal Services You Seek *

Representation On Retainer

One Hour Phone Consultation

Contingent Fee

None of these

Select any low cost resources you are interested in *

Where did you hear about me? *