Roger - Roger

Who are you requesting help for?

Self

Friend/Family Member

Please note that you’re submitting a request for help on behalf of another individual.

We’ll follow up with you directly and explain the procedure for connecting with your friend or family member.If you’d prefer for your friend or family member to submit a request directly on their own behalf, they can do so by clicking “Self” on the first page of this form.

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What branch of the military did theyyou serve?

Army

Marine Corps

Navy

Air Force

Coast Guard

I didn't serve

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First, we need to collect some basic information. This process is completely confidential.

First Name*

Last Name*

Date of Birth* mm/dd/yyyy

Gender*

Zip*

State Enter your zip code

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First, we need to collect some basic information about you. This process is completely confidential.

First Name*

Last Name*

Age Group*

Gender*

Zip*

State Enter your zip code

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Now we need to know how to contact you. This process is completely confidential.

Phone* xxx-xxx-xxxx

Email*

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Can you tell us more about why you’re reaching out for your friend or family member? Check all that apply. Can you tell us more about why you’re reaching out today? Check all that apply.

Mental Health Needs

PTSD-Related Needs

TBI-Related Needs

Substance Abuse Issues

Relationship Problems

Financial Problems

Housing Insecurity

Chronic Pain / Disability

Assistance Navigating the VA

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Will you tell us more about what your friend or family member is feeling? Check all that apply. Will you tell us more about what you’re feeling? Check all that apply.

Hopeless

Trapped / Helpless

Guilty

Shameful / Self-Hateful

Isolated

Anguished / Miserable

Anything you want to add?

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One final question regarding your friend or family member’s safety and wellbeing. One final question concerning your safety and wellbeing.

Is your friend or family member currently having thoughts of killing themself?Are you currently having thoughts of killing yourself?*

By checking this box, I acknowledge that I am 18 years of age or older.*

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As a reminder, you can reach us by phone 24/7 at 833-697-6437. If you’re having thoughts of killing yourself, we strongly urge you to call and speak with us immediately. Calling now is the fastest way to speak with a ROGER team member.

Sending

Who are you requesting help for?

Please note that you’re submitting a request for help on behalf of another individual.

What branch of the military did theyyou serve?

First, we need to collect some basic information. This process is completely confidential.

First, we need to collect some basic information about you. This process is completely confidential.

Now we need to know how to contact you. This process is completely confidential.

Can you tell us more about why you’re reaching out for your friend or family member? Check all that apply. Can you tell us more about why you’re reaching out today? Check all that apply.

Will you tell us more about what your friend or family member is feeling? Check all that apply. Will you tell us more about what you’re feeling? Check all that apply.

One final question regarding your friend or family member’s safety and wellbeing. One final question concerning your safety and wellbeing.