Inquiry Form
The Gary Sinise Foundation Avalon Network is a cognitive health and mental wellness network providing transformative care to veterans and first responders experiencing post-traumatic stress, traumatic brain injuries and substance abuse. The Network provides integrative traumatic brain injury and post-traumatic stress treatment and training to help heal the invisible wounds afflicting our veterans and first responders.

Please answer the following questions so that our team can best route you to the appropriate care provider or resource within the Network.

Please complete this form in its entirety. Following submission, a member of the Gary Sinise Foundation Avalon Network will be in contact with you.

IMPORTANT NOTE: We do not accept inquiries filled out on behalf of others. All applicants must be a veteran or first responder directly seeking to receive services from the Gary Sinise Foundation Avalon Network for themselves.
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Email *
First Name *
Last Name *
Zip Code of Primary Residence *
Phone Number *
Please choose the selection below which best describes your current status: *
Have you deployed to a combat zone? *
Did you serve in the military after September 11, 2001? *
In your lifetime have you ever injured your head or neck (examples: vehicular accident, blasts, falls, breaching operations, airborne operations, being shot, strike to the head, sports, etc.) *
Have you ever been diagnosed with or been told you may have any of the following: Select all that apply. *
Required
Based on the following summary of symptoms, please select one of the four options below that best describes your experience so that our team can route you to the appropriate care provider or resource. Note, although more than one option may apply, please choose the ONE OPTION that most closely matches your most urgent and pressing needs. *
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