Client Intake Form

Please enter your request below.

Who is requesting services ?

First Name *

Last Name *

Email Address *

Phone Number *

Preferred Contact Method

Street Address

City *

State / Province *

Country *

Zip Code *

Birthday *

Please enter the birthday of the person seeking assistance. If birthday is unknown, please enter 01/01/1901 as the birthday.

Gender *

Are you a Veteran? *

Are you a Dependent / Spouse? *

How may we assist you ?

Military Transition

Employment Resources and Assistance

For Service Providers – Referred From

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Contact Us

Virginia Department of Veterans Services
Commissioner John Maxwell
600 East Broad Street, 2nd Floor
Richmond, VA 23219
info@dvs.virginia.gov
Phone: (804) 786-0286
844-VDVS-VET or 844-838-7838
Fax: (804) 786-0302

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