Please complete this form PRIOR TO you initial consultation.

Contact information: Veteran Information

Prefix

First name *

Middle name

Last name *

Date of birth

Emails

Email Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Phone numbers

Phone number

Type

Add phone number

Preferred Method of Contact

Marital Status

Social Security Number

VA File number

Branch of Service

Character of Discharge

Goal of representation (e.g., I want to appeal the denial of service connection/the rating for...)

Within the past year, have you received a rating decision from VA?

Yes

No

Are you currently employed? If not, when did you last work, and why did you stop working?

Are you receiving SSA disability?

Are you currently, or have you been, represented by a law firm/agent/veteran service organization before VA? If so, who?

How did you hear about Castillo Law, PLLC?