Veteran Intake Form

Please fill out this form to help us understand your needs and provide the best possible service.

Before you start

Who should complete this: Veterans, service members, and family members coordinating care who want to connect with Florida Veterans Coalition programs statewide.

What you'll need: Contact details, referral/source information, and a summary of how we can help. Optional service history fields help us route you faster.

What happens next: Our team reviews your intake and follows up within several business days using your preferred contact method, depending on volume.

Submissions are protected by Cloudflare Turnstile and secure processing. See our Privacy Policy.

Intake details

Intake Date *

Contact made via *

Referred by *

Personal information

First Name *

Last Name *

Email Address *

Phone Number

Address *

City *

County *

State *

ZIP Code *

Date of Birth *

Gender *

Military service

Duty Status *

Branch of Service *

Dates of Service *

DD-214 Status *

Combat Veteran Status *

VA & assistance

VA Enrollment *

Currently pursuing assistance? *

Primary assistance source *

Service-Connected Status *

Service Connection Percentage

Receive VA medical care? *

VA Facility

Needs & follow-up

Optional — helps us tailor our outreach.

Referral Source

Service Interests

Urgency Level (1–5)

Additional Information

Consultation Scheduling

Support Areas (select up to 3)

VA Claims Process Confidence (1–10)

Contact Time Preference

Intake Notes

Email updates consent

I agree to receive future email updates from Florida Veterans Coalition, including organizational news and opportunities. Florida Veterans Coalition may still contact me about this submission even if I leave this unchecked. I understand I can unsubscribe at any time.

Frequently asked questions

Who should complete the veteran intake form?

Veterans and transitioning service members who want to connect with Florida Veterans Coalition programs — from VA claims education and employment to peer support and events.

What happens after I submit?

Our team reviews your intake and reaches out using the contact method you prefer, typically within several business days depending on volume.

What information will I need?

Basic contact details, service background, and how we can help. You do not need a DD-214 to start, but sharing what you have speeds matching you to the right resources.

Is there a cost?

There is no fee to submit intake or to receive navigation help for coalition services described on our site.

Can family members submit on behalf of a veteran?

A family member may help complete the form with the veteran’s consent. The veteran should be the person seeking services unless you are coordinating for a dependent in crisis.

How is my data protected?

Submissions are protected by honeypot checks, timing validation, and Cloudflare Turnstile before reaching our secure backend. See our Privacy Policy for details.

Looking for a Peer Mentor?

Our peer mentor program pairs Veterans with trained mentors who understand the military experience.

Become a Peer Mentor