Veterans' Advocacy Service referral form

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Please read the Client Disclosure Statement before proceeding

You must read the Client Disclosure Statement (PDF, 602 kb) before proceeding with this form.

Title

First name*

Last name*

Email address*

Date of birth*

Phone number*

Address*

State*

Postcode*

Date of enlistment

Date of discharge

What condition(s) do you suffer from?*

When did you first notice your condition(s)?*

PMKeyS

Are you currently receiving/have you ever received a DVA benefit? If so, what type?*

DVA File no.

How can we help you?*

How did you find out about our service? (Put N/A if no one referred you)*

To submit this form you must type in 'yes' to confirm that you have read our Client Disclosure Statement and agree to the way we treat your confidential information. If you have not read the Client Disclosure Statement, there is a link to the statement at the top of this page.*

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Veterans' Advocacy Service referral form

Please read the Client Disclosure Statement before proceeding