EmailMe Form - Buddy Request Form-I need a Buddy to contact me.

Name *

First Last

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

Phone *

### - ### - ####

How long at the above address? *

Last four digits of your social security number: *

Emergency contact name & relationship: *

Emergency phone number: *

Have you been diagnosed with PTSD? *

Yes

No

Have you been diagnosed with other mental health issues? *

Yes

No

If yes,please list additional diagnosis:

Are you currently being treated by a DOCTOR or the VA for you PTSD? *

Yes

No

If yes, name and phone number of Doctor or VA Clinic and VA Doctor name?

Are you a caregiver for someone with PTSD? *

Yes

No

Are you seeking help from other organizations for your PTSD? *

Yes

No

If yes, please list those organizations:

Are you current or previous Military? *

Yes

No

If so, what Military Branch and your MOS:

Where & When Deployed:

Military Service Dates:

If Civilian: Your Occupation:

Are you currently employed? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

If yes, please explain:

Are you having serious financial problems? *

Yes

No

If yes, please explain:

Are you having legal issues? *

Yes

No

If yes, please explain:

Are you a parent? *

Yes

No

Are you: *

Single

Married

Divorced

Separated

Briefly explain what caused your PTSD? *

What are your most debilitating symptoms of PTSD? *

Are you having thoughts of suicide? *

Yes

No

Sometimes

If yes, do you have a plan in place?

Yes

No

Below are the areas that PTSD Projects can provide help. Are you in urgent need of help?

Please check below only the areas that you are needing help.

Buddy/Mentor:

Male

Female

No Preference

Service Dog:

Need training only

Need a dog and training

VA Medical Treatment:

Need help with a medical issue

Need appointment

Need to file a complaint

VA Claim:

Need help with denied claim

Need help with new claim

Civilian Services:

Need help finding counseling

Looking for support group

Other

Explain Other:

How do you need for PTSD Projects to help you with the items checked above? Please give brief details for each item.

While PTSD Projects will do their best to assist you, we are not always able to provide you with the access to the service you have requested. A lot of our success depends on your active participation.

DISCLAIMER:
PTSD Projects is made up of both military and civilian volunteers that have experienced PTSD either personally or as a caregiver. We are not mental health professionals. Anything we discuss with you is based on our personal experiences or opinions and is not to be taken as professional advice or treated as a professional service. We care and we do not judge. PTSD Projects is not liable for any actions taken by you at any time while you are associated with PTSD Projects and/or your PTSD Projects Buddy or following your association with PTSD Projects. By submitting this PTSD Projects questionnaire and by checking the yes box below, you are agreeing to this DISCLAIMER. In order for a representative of PTSD Projects to talk on your behalf to the VA and/or outside providers, additional paperwork will be needed by us. We are not able to help with any mental health issues other than PTSD and should it be suspected or determined by a PTSD Projects volunteer that there may be additional mental health issues or on a rare occasion, when it appears that we are not effective in helping you, we will suggest other avenues of help, but will have to discontinue our service to you. We hope we will be a help to you in your battle with PTSD. Thanks for reaching out to PTSD Projects.

By answering YES to the box below, it acknowledges that I have fully read the DISCLAIMER included in this PTSD Projects questionnaire and fully understand the contents.

YES