Veteran Triage

Veteran Triage form

A Veteran is defined as a person who is serving or has served in the ADF. If you fit this definition then you are a Veteran. If you are a Veteran or a Family member of a Veteran and you need assistance then please complete the following Triage form. This webform will be sent automatically to a Network Duty Advocate.

Our objective is to provide the best possible support to Veterans and Families and the following information will help us support you effectively more quickly.

We also accept referrals from all organisations supporting Veterans and their Families.

After we receive your completed form we will contact you as soon as we can.

Please complete this form:

Name *

First

Middle

Last

Date of BirthDD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Email *

Email

Confirm Email

Mobile Phone Number

Please insert you Mobile Phone Number

Home Phone Number

Please insert another phone number if you have one.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountry

Gender

• Female
• Male
• Prefer not to say

PMKeys or Service Number

Please insert you PMKeys number OR your Service Number.

Service

• RAN
• Army
• RAAF
• Other

Please indicate which Service(s) your served in. You can indicate one, two or three.

Service Category

• Permanent
• Reserve
• Both

Please your Service category.

Enlistment Date *

DD/MM/YYYY

Discharge or Current (if still serving) Date *

DD/MM/YYYY

Mode of Discharge

• J51 Medically Unfit
• J52 Non Effective
• Administrative
• At Own Request
• Reached Retirement Age
• Made Redundant
• Compulsorily Transferred to the Reserves

Please indicate which mode of discharge you were discharged. Select only one.

Deployment / Operations details (if any):

Please list the deployments and/or operations you were a part of. These were usually overseas.

If you have a DVA Card, what is your DVA File Number?

If you have a DVA Health Card your DVA File Number will be written on your Card.

Your Wellbeing Status

Please answer the following questions to determine your wellbeing status.

Are you OK?

• Suicidal
• Anxious/Depressed/Self-destructive
• Good

Please indicate which response is closest to how you feel.

How safe are you?

• Being abused/assaulted
• Feeling unsafe
• Safe

Please indicate which response is closest to how you feel.

How good is your housing?

• Sleeping rough
• With friends / Family
• Comfortable

Please indicate which response is closest to your current sleeping arrangements.

Do you have someone to rely on?

• No one at all
• Close Partner / Family
• Many family and friends

Please indicate which response is closest to current relationship.

Are you employed?

• Retired
• Unemployed
• Part-time/Casual/Gig work
• Fully employed

Please indicate which response is identified your current employment status.

Does your income cover expenses?

• Going further into debt
• Just making ends meet
• Able to afford outings

Please indicate which response is closest to current financial status.

How is your health?

• Life threatening/ Debilitating
• Serious, but coping
• No restrictions to living

Please indicate which response is closest to how you feel.

Please briefly indicate the services you require in the following text box:

Response

Submit

Next actions

We will contact you as soon as possible after we receive your completed form.
As we are all volunteers, we are not able to ensure a same-day service.
If we do not reply within seven days, ring 02 5621 8108 leaving your name and contact number. Thank you in advance for your understanding.
Veterans Wellbeing Advocacy Team