First Name

Last Name

Middle Initial

DOB

Street Address

City

State

Zip Code

Phone

Email

Service (check all that apply)
Air-forceArmyCoast GuardMarinesNavyNational GuardLaw EnforcementFireEMTCorrections

What is Your Disability Rating? (if Any)

Types of Injury(ies) - Please be Specific

Any Addictions or Allergies?

Interests or Hobbies - (check all that apply)
HikingCampingFishingVolunteeringArcheryCaregiver SupportFundraisingAdaptive Recreation

Other Interests

In What Areas Are You Looking for Help?
PTSDAnxietyDepressionStress/Anger ManagementMoney Management/FinancialFamily SupportHousingVA AssistanceNeed a new mission in life

Other Needs

How Did You Hear About OHD?