Military Medical Depression Waiver Request Form
Submit your request for a medical/depression-related waiver in a military context. Please provide all required information and supporting documentation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Military Status
*
Active Duty
Reserve
National Guard
Veteran
Service Branch
*
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Rank/Rate
*
Unit or Installation
*
Date of Depression Diagnosis or Onset
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Treatment or Medication Status
*
Under treatment (medication and/or therapy)
Completed treatment
Not currently receiving treatment
Other
Reason for Waiver Request / Explanation
*
Upload Supporting Documentation
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Follow-Up Contact Method
*
Email
Phone
Signature
*
Submit Waiver Request
Submit Waiver Request
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