31640 U.S. Hwy 19 N. Suite #2 Palm Harbor, FL 34684

(727) 781-HERO (4376)

Tablets for Heroes Program Application

Tablets for Heroes Program

Tablets for Heroes program provides tablet computers to veterans to help with symptoms of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injuries (TBI), including disorganization, forgetfulness, and disorientation.

The cause of PTSD must have been incurred or aggravated in the line of duty in Iraq or Afghanistan after September 11, 2001.

You must provide Healing Heroes Network with a copy of your DD Form-214 and/or your last duty orders before we can complete your application process. You can upload them now for faster processing.

* Required Information

Applicant's First Name (*)
Please type in your first name.
Applicant's Last Name (*)
Please type in your last name.
Gender (*)
Please select your gender.
Date of Birth (*)
Please select you date of birth
Street Address (*)
Please type in your street address.
City (*)
Please type in your city.
State (*)
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ZIP Code (*)
Please type in your ZIP code.
Phone (*)
Please type in your phone number.
E-Mail (*)
is not a valid e-mail address.
Branch of Service
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Current Military Status (*)
Please select your current Military Status.
Do you suffer from PTSD and/or TBI? (*)
Please select your answer.
Were you deployed to Iraq and/or Afghanistan after 9/11/01? (*)
Please select your answer.
Have you received any treatment for PTSD and/or TBI? If so, how were you treated and by whom? (*)
Are you currently being treated for PTSD and/or TBI? If so, how and by whom? (*)
How Did you Hear About Healing Heroes Network?
Please select how you heard about us.
If Other, please specify
If you selected "Other", please specify.

By submitting this form, I confirm that the above information is correct. I understand that completion of this form does not guarantee that the services requested will be provided.

I hereby give Healing Heroes Network permission to leave messages on my phone and to access my medical records, in accordance with HIPAA. I understand that Healing Heroes Network will not use my records for any other purpose, or give my information to another party.

Electronic Signature (*)
Please sign by typing your name.
Date (*)
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Security Verification (*) Security Verification
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into the box.

National Charity

31640 U.S. Hwy 19 N. Suite #2 Palm Harbor, FL 34684

by phone: (727) 781-HERO (4376) - Local

by e-mail: info@healingheroes.org

or fill in the form on our contact page

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