First Initial

Last Name

Age

Gender

Phone

Email

What state are you a resident of?

Dates of Service

Start month/year

Dates of Service

End month/year

Branch of Service

Are you a combat veteran?

YesNo

What is your discharge status?

Honorable DischargeGeneral Discharge Under Honorable ConditionsOther Than Honorable (OTH) DischargeEntry-level SeparationMedical SeparationSeparation for Convenience of the GovernmentBad Conduct Discharge (issued by special court-martial or general court-martial)Dishonorable Discharge

What is your disability rating from the Department of Veteran Affairs (VA)?

Do you have a caregiver?

Is your caregiver registered with the VA?

Does your caregiver receive a stipend?

Is your caregiver aware that they may be eligible to receive a stipend if they currently do not receive one?

Are you aware of the services provided to you by the VA?

If yes, which ones

Do you currently use any of the services provided to you by the VA system? If yes, which ones do you currently use?

If yes, which ones

As a veteran, have you ever experienced any suicidal ideations?

Do you personally know another veteran who has attempted or committed suicide?

Have you ever had a family member attempt or commit suicide?

Are you currently divorced?

If yes, how many times

If you are or have been divorced, was your mental health a factor in your marriage?

Has your current or former spouse ever suggested marital counseling and you refused to participate?

Has your physical or mental health ever created a financial strain in any of your relationships (coworkers, friendships, significant other, marital, family, or parental)?

After leaving active duty, did you suffer undue stress or neglect your mental health due to the requirement for health and life insurance and/or financial security for you and/or your family?

If yes, can you explain *Optional*

Would one year of free or low-cost medical insurance for you and your family have helped to ease your transition from active duty to veteran life and would it have encouraged you to engage in self-care through the VA?

Do you feel that you are not entitled to certain services or benefits, or did not receive services and benefits provided by the VA or other support organizations because you failed to meet specific eligibility criteria? For example: because you were not a purple heart recipient or combat veteran.

If yes, can you explain *Optional*

What type of family services or activities would you like to see provided in your community that you or your family would benefit from?

Were there any transitional services that you or your family needed that would have made your transition easier and more successful?

Veterans Survey