Sample website. A fictional organization, not affiliated with the VA.

Talk to the Veterans Crisis Line now

If you are a veteran in crisis or worried about one, connect with caring, qualified responders. Free and confidential, 24 hours a day, 7 days a week. You do not have to be enrolled in VA benefits or health care.

If you are in immediate danger, call 911 or go to the nearest emergency room.

Get more resources at VeteransCrisisLine.net (opens in a new tab)

 (916) 555-0142Contact usEspañol

Web form

New Client Intake Form

Please complete all sections. This form takes about ten minutes.

How to use this form

Fill it in on screen and print it, or print it blank and fill it in by hand. Bring it to our office or mail it to 1450 Sample Address Drive, Suite 200, Sacramento, CA 95814. This page does not send anything. It is a demo site, and your answers stay on your device.

Download the PDF (PDF, 5 KB, 1 page), opens in a new tab

1. Contact Information

2. Military Service Information

Have you filed a VA claim before?

3. Household Information

4. Services Requested

Which services do you need? Select all that apply.

Sign and date the printed form before you hand it in.

Submit completed forms in person, by mail, or by email. See our Contact page for details.

Need help filling this out? Call (916) 555-0142.

Back to all forms

Need help?

Call us

(916) 555-0142

Free and confidential.

Monday to Thursday, 8:00 AM to 6:00 PM.

Friday, 8:00 AM to 4:00 PM.

Visit us

1450 Sample Address Drive, Suite 200
Sacramento, CA 95814

Walk in during office hours. No appointment needed for intake. Hours and directions

In crisis?

Veterans Crisis Line, 24/7: dial 988 then press 1, or text 838255.

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