EmailMe Form - VA Medical and Mental Health Grievance Report

Name of Involved Veteran *
First Middle Last
Veteran's Date of Birth *
Veteran's SSN *
Name of Person Completing Form If Other Than Veteran *
First Last
Relationship to Veteran *
Veteran's Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Veteran's Daytime Phone *
### - ### - ####
Veteran's Email *
Daytime Phone of Person Completing This Form *
### - ### - ####
Name of VA Office or Facility Involved *
Street Address of the VA Facility Involved *
City and State where the VA Facility is located *
Name of Veteran's Primary Care Doctor *
Name of Veteran's Mental Health Doctor *
Date(s) When This Incident Occurred. *
Alleged Legal or Policy Violation(s) or Other Misconduct or Mistreatment *
How Did This Wrongdoing Effect You Mentally, Physically, Financially? *
Names of Wrongdoers *
Names of Other Victims Affected by This Wrongdoing *
Names of Witnesses *
Has This Allegation Been Previously Reported? *
If Yes, Please Provide the Date and the Name of the Person To Whom It Was Reported *
If Previously Reported, What was the Outcome? *
How Do You Rate Your VA?

Very Unsatisfied Unsatisfied Satisfied Very Satisfied

Care & Compassion 1 2 3 4

Responsive to my Needs 1 2 3 4

Polite and Courteous 1 2 3 4
Overall Satisfaction

	Very Unsatisfied	Unsatisfied	Satisfied	Very Satisfied
Care & Compassion	1	2	3	4
Responsive to my Needs	1	2	3	4
Polite and Courteous	1	2	3	4

Rate Your VA Mental Health Doctor

	Very Unsatisfied	Unsatisfied	Satisfied	Very Satisfied
Understanding of PTSD and Its Effects on Me	1	2	3	4
Personalized Treatment	1	2	3	4
Caring and Compassionate	1	2	3	4
Knowledgable of Therapies and Medications for PTSD	1	2	3	4
Trust	1	2	3	4
Understanding of Military Lifestyle	1	2	3	4
Nationality	1	2	3	4

Have A Say in Your VA Mental Health Treatment?

	Not Important	Somewhat Important	Important	Very Important
Treatments and Therapies	1	2	3	4
Medications including medical marijuana	1	2	3	4
Number of Counseling Sessions per Month	1	2	3	4
Options for In-patient treatment	1	2	3	4

Rate Your VA Primary Care Doctor

Very Unsatisfied Unsatisfied Satisfied Very Satisfied

Timeliness 1 2 3 4

Care & Compassion 1 2 3 4

Knowledgeability 1 2 3 4

Trust 1 2 3 4

Nationality 1 2 3 4
Overall Satisfaction
What Changes Within the VA Would You Like to See?
Would You Like to Have the Option of Being Treated by a Civilian Doctor or Mental Health Professional?
Definitely
Probably
Not Sure
Probably Not
Definitely Not
By signing this grievance, I agree that all statements are true to the best of my knowledge. I understand that this grievance report will by used by PTSD Projects in an effort to create awareness of specific issues that are taking place within VA facilities across the country. The goal of myself and PTSD Projects is to help bring about positive changes within the Veterans Administration regarding treatment and care of our nation's veterans. *
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