Expenses Reimbursement Form | Warrior For Life Fund

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info@warriorforlifefund.org

(833) 935-3863

Warrior For Life Fund

309 Aragona Blvd
Suites 107-108
Virginia Beach, VA 23462

Synapse Integrated Therapy Center
309 Aragona Blvd
Suites 101-103
Virginia Beach, VA 23462

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Warrior For Life Fund

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Synapse Integrated Therapy Center

Thank you for your interest in the Synapse Integrated Therapy Center. Please answer the questions below to the best of your ability. Your responses will be kept confidential in accordance with HIPAA and healthcare privacy regulations. If you need any additional support, feel free to contact us at synapse@warriorforlifefund.org. Thank you!

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About You

Your Name*

First Last

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Email Address*

Email Address Confirm Email Address

D.O.B.

Month

Day

Year

Your Phone*

Preferred Method of Contact*

Phone

Email

Text

I am*

a Retired Veteran

a Separated Veteran

an Active-Duty Service Member

a transitioning Service Member (<2 years from separation)

Do you live in Hampton Roads?

Yes

No

Are you EXW qualified?

Yes

No

Not Sure

Prease provide rate/rank and relative assignment history?

Do you have a documented TBI (including concussion or blast exposure history)?*

Yes

No

I have experienced these, but they are not documented

Have you been to a program for TBI such as Home Base, NICoE, or other? If yes, please list which one and when*

Yes

No

Please list which program and when

Primary Care Provider Name

Who is your current primary healthcare or insurance provider (e.g. Tricare Select, Anthem)?*

Are you able to commit 3 hours at a time, one day a week, for 12 weeks?*

Yes

No

Other

What goals or challenges are you hoping to address through therapy at Synapse?*

Please add and additional Comments/Questions

Synapse Integrated Therapy Center_

Thank you for your interest in the Synapse Integrated Therapy Center. Please answer the questions below to the best of your ability. Your responses will be kept confidential in accordance with HIPAA and healthcare privacy regulations. If you need any additional support, feel free to contact us at synapse@warriorforlifefund.org. Thank you!

Δ

This field is for validation purposes and should be left unchanged.

About You

Your Name(Required)

First Last

How Can We Reach You?

We would love to chat with you. How can we get in touch?

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Preferred Method of Contact(Required)

Phone

Email

Text

I am(Required)

a Retired Veteran

a Separated Veteran

an Active-Duty Service Member

a transitioning Service Member (<2 years from separation)

Do you have a documented TBI (including concussion or blast exposure history)?(Required)

Yes

No

I have experienced these, but they are not documented

Have you been to a program for TBI such as Home Base, NICoE, or other? If yes, please list which one and when(Required)

Yes

No

Please list which program and when

Who is your current primary healthcare or insurance provider (e.g. Tricare Select, Anthem)?(Required)

Are you able to commit 3 hours at a time, one day a week, for 12 weeks?(Required)

Yes

No

Other

What goals or challenges are you hoping to address through therapy at Synapse?(Required)

Please add and additional Comments/Questions