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UPDATE AGAIN***UPDATE on RFE for my husband


AirForceVetsWife

Question

The claim is complete. They've mailed our packet.

 

on SC disabilities list on ebenefits it used to say Major Depressive Disorder and now it says "Major Depression (Previously diagnosed as Major Depressive Disorder)" Is that a bad sign? or are they calling MDD Major depression now? Everything I've read it says Major depression IS major depressive disorder.

Now I'm worried that this is a reduction thing.

 

This is what the American Psychiatric Association says:

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.

Depression symptoms can vary from mild to severe and can include:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed movements and speech (actions observable by others)
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

Symptoms must last at least two weeks for a diagnosis of depression.

 

I think I'm just getting myself super hyped up

 

Ok, I really think I'm just worrying myself for nothing because it says MDD is also known as Major Depression

 

 

 

Ok, sorry you all...I just wanted to be sure to update you all. I got his C&P this morning.

I was feeling good about it because the social/work impairment that was checked was the same as his first C&P back in 2013 when he was initially rated at 70%. Well, looking at the ratings...the one that was checked then and now is under 50%....so now I'm confused.

 

The biggest thing I see, is at the end of the new exam, the doctor put "His current mental health status is the progression of his major depressive disorder" So that doesn't show that he's better

 

But, here's the C&P with personal info redacted

 

Mental Disorders

(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

Request?

[X] Yes [ ] No

SECTION I:

----------

1. Diagnosis

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes [ ] No

If the Veteran currently has one or more mental disorders that conform to

 

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: MAJOR DEPRESSION

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): HTN, HX OF TACHYCARDIA, HX OF

RIGHT SHOULDER SURGERY.

2. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

3. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with reduced reliability and

productivity

b. For the indicated occupational and social impairment, is it possible to

differentiate which impairment is caused by each mental disorder?

[ ] Yes [ ] No [X] Not Applicable (N/A)

c. If a diagnosis of TBI exists, is it possible to differentiate which

occupational and social impairment indicated above is caused by the TBI?

[ ] Yes [ ] No [X] Not Applicable (N/A)

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence Review

------------------

Evidence reviewed (check all that apply):

[X] VA e-folder

[X] CPRS

[X] Other (please identify other evidence reviewed):

PRIOR CXP EXAMS.

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

 

post-military):

, WAS DRIVEN HERE BY HIS WIFE AS HE

DOES NOT DRIVE MUCH ON HIGH WAY.HE IS MARRIED SINCE 2008, ONLY

MARRIAGE,HAS 2 DAUGHTERS.THIS VET WAS AIR FROCE VET,SERVED FROM 2007 TO

2012.DURING HIS CARRIER, HE WAS STATE SIDE,NOT IN ANY WAR ZONE. HIS

MOTHER AND SISTER LIVE LOCALLY.

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

SINCE DC FROM AIR FORCE, HE HAD 5 JOBS,HIS LONGEST JOB WAS FOR TRACTOR

SUPPLY FOR 3 YRS. SINCE LAST ONE YR, HE IS WORKING FOR LOWES FULL

TIME.

HE WAS NEVER FIRED FROM ANY JOB, WENT FOT BETTER PAYING JOB.MANY OF HIS

JOBS WERE SEASONAL JOBS.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

HE IS CURRENTLY NOT IN ANY MH CARE.HE DID RECEIVE MH CARE WHILE IN AIR

FORCE.HE HAS PROBLEMS WITH SLEEP, DIFFICULTY FALLING A SLEEP, WAKING UP

AND SOME TIME DIFFICULTY FALLING A SLEEP. DAY TIME HE FFELS TIRED. HE

ISOLATES HIM SELF FROM OTHERS.IN THE PAST HE USED TO ENJOY OUT DOOR BUT

NOT ANY MORE, LOST INTEREST.WHEN HE IS DEPRESSED, HE STAYS BY HIM SELF

AND AVOIDS OTHERS.HE DOES NOT LIKE TO BE OUT AWAY FROM HOME, HE FEELS

INSECURED AND BECAUSE OF THIS HE FEELS ANGRY AT HIM SELF.AT WORK HE

TRIES TO PUT SHOW THAT HE IS FEELING GOOD BUT IN REALITY, HE DOES NOT

FEEL GGOD. IF HE HEARS CRYING BABY, HE WANTS TO GO HOME AND BE WITH HIS

KIDS.AT HOME HE DOES NOT LIKE TO INTERACT WITH HIS WIFE AND KIDS BUT

BEING AT HOME HE FEELS VERY SECURED.OFF AND ON HE FEELS WORTHLESS, AND

AT WORK HE FEELS THAT HE IS GOING TO GET FIRED AND THAT MAKE HIS JOB

HARDER TO DO.

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

NONE

e. Relevant Substance abuse history (pre-military, military, and

post-military):

NONE

f. Other, if any:

NA

3. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

 

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Chronic sleep impairment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or

a

worklike setting

4. Behavioral observations

--------------------------

ALERT,ORIENTEDX3,COOPERATIVE,POOR EYE CONTACT. AFFECT IS CONSTRICTED,

DYSPHORIC MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY OTHER

PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT.

5. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Yes [X] No

6. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

7. Remarks (including any testing results), if any:

---------------------------------------------------

THIS VET CONTINUES TO EXPERIENCED SXS OF DEPRESSION SUCH AS INSOMNIA, LACK

OF

ENERGY, LACK OF INTEREST, ANHEDONIA, WORTHLESS, SOCIAL ISOLATION. THESE HAS

AFFECTED HIS JOB BUT SOME HOW HE COULD KEEP THE JOB, WITH UNDERSTANDING THAT

HE HAS TO SUPPORT HIS FAMILY.

HIS CURRENT MENTAL HEALTH STATUS IS THE PROGRESSION OF HIS MAJOR DEPRESSIVE

STATE.

/es/ PRAMOD A SHAH, MD

Signed: 05/10/2019 10:45

 

 

 

This was his first one in 2013

 

 

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes[ ] No

If the Veteran currently has one or more mental disorders that conform to

DSM-IV criteria, provide all diagnoses:

Diagnosis #1: Major Depressive Disorder

ICD code: 000

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Hypertension,,Tachycardia

ICD code: 000

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

Moderate - financial

d. Axis V - Current global assessment of functioning (GAF) score: 55 - 60

2. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes[X] No

b. Is it possible to differentiate what symptom(s) is/are attributable to

 

each diagnosis?

No response provided.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[X] No[ ] Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to

each diagnosis?

No response provided.

3. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with reduced reliability and

productivity

b. For the indicated level of occupational and social impairment, is it

possible to differentiate what portion of the occupational and social

impairment indicated above is caused by each mental disorder?

[ ] Yes[ ] No[X] No other mental disorder has been diagnosed

c. If a diagnosis of TBI exists, is it possible to differentiate what

portion

of the occupational and social impairment indicated above is caused by

the

TBI?

[ ] Yes[ ] No[X] No diagnosis of TBI

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence review

------------------

If any records (evidence) were reviewed, please list here:

VBMS, CPRS

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

Veteran denies family history of mental illness.He is married with 2

children (2,1 year old) in Paris,Tn. Due to his depressive symptoms

they are having domestic issues.He tends to isolate a great deal.He

has

very few activities he does that he enjoys to do.

b. Relevant Occupational and Educational history (pre-military, military,

and

 

post-military):

The Veteran graduated from High School. he served in the Air Force

from

7/24/2007 - 3/27/2012. He was not in combat.He was honorably

discharged

at E4 rank.Since discharge he has been working in the receiving

department of a tractor supply company in Paris,Tn. The Veteran's

productivity and reliability have been decreasing both at work and at

home.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

He denies pre - military mental problems. His depressive symptoms

gradually came in while in the service. By Christmas 2011 he notice

fatigue, sadness, poor concentration.His depression increased over the

next many months.His depressive symptoms are manifested by feelings

sad

most of the day, ahedonia,difficulty sleeping, fatigue, poor self

esteem, decreased libido and difficulty concentrating.He sought help

for these symptoms by Nov.2011 while in the service. The first

documentation I could find was in his problem list from his VBMS note

on 11/16/2011.Because of cardiac problems he says he was not started

on

antidepressant medication.He felt it was very stressful in the

military

not to be able to do mechanic work in service because of his right

should problems. He felt this stress was a possible trigger for his

depression.He says he did see a counselor while in the service. Since

discharge he has continued to have symptoms of depression. He is not

getting mental health treatment nor dis he on any psychotropic

medication.There is a mention of ADHD in his record but at the present

time he feels this is not an issue for him. He is not hyperactive.

His

concentration difficulty appears more related to his general

depression

at the present time. He denies manic - like episodes.

Mental Status Evaluation today.

General appearance is WNL.

Veteran showed no unusual gestures or grimaces.

Affect was flat.

The veteran is oriented in all 3 spheres.

General information WNL.

Recent and remote memory intact.

Number sense WNL including subtracting serial sevens.

Veteran denied auditory and visual hallucinations and/or delusions.

Veteran denied wanting to harm or kill himself or others.The Veteran

denied suicidal or homicidal ideation or intent.

 

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

None.

e. Relevant Substance abuse history (pre-military, military, and

post-military):

He denies illegal drug use and rarely has an alcoholic

beverage.Veteran

denies any previous alcohol or drug treatment.

f. Sentinel Event(s) (other than stressors):

No response provided.

g. Other, if any:

No response provided.

3. Symptoms

-----------

For VA rating purposes, check all symptoms that apply to the Veteran's

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[X] Flattened affect

[X] Difficulty in understanding complex commands

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or

a

worklike setting

[X] Inability to establish and maintain effective relationships

4. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Y

es[X] No

5. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes[ ] No

6. Remarks, if any:

-------------------

 

The criteria contained in DSM-1V are being used until the time of

transition to DSM-V.I suggested the Veteran seek Mental Health treatment

for his Depression symptoms.

****************************************************************************

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran: Reed, Jeremy Scott

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

a. Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VBMS, CPRS.

MEDICAL OPINION SUMMARY

-----------------------

So great...they checked less boxes this time...this really doesn't look good...

Edited by AirForceVetsWife (see edit history)
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Roger That AirForceVetsWife

Hang in there!!!

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Yes they should carry some weight but I never seen them on the exam if the examiner don't include them the rater will not see them  unless you submitted them as evidence in time?

If not I see a  stay the same rating at 70%  but it also could be a reduction  just have to wait and see the decision?

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I am rather shocked that you got a copy of this exam so soon.

Have you googled the doctor to see what their credentials are?

I assume this was a VA doctor and not a Contracting doctor- because they usually do not release C & P exams from the contractors until they make a decision.

I received a C & P exam copy that was done posthumously on my husband in 2015, by a VA doctor, not a contractor.

At first I didnt feel I need it ,for years, because I won that cue within a month  after the denial under CUE.

But due to other circumstances, I requested it.

The VA had my sole piece of evidence from the top cardiologist in VACO, DC.

The denial listed it as evidence but it was never considered and my CUE filed the next day immediately reversed the decision.

The C & P I got is so deficient that I filed a White House Hot Line complaint on it last week.

The "examiner" is an internist , who is employed by the VA  and the rhetoric shows she never even looked at the VACO opinion or  (I assume) very few of my husband's medical records.

She also had to write addendum because she first stated this was an "in" person exam.

By time of this exam my husband had been dead for 19 years.

I also requested the third page of a past C & P exam I was present at, done in my husband's lifetime.

A VA Neurologist declared him 100% P & T at that exam.(1151 stroke)The director of my RO told me, he was 100% Total at death but not permanent.That is a ridiculous statement and defies VA case law.All of my medical evidence (to include other evidence from VA, Voc Rehab, Agent Orange Commission, VA doctor signing  student loan waiver ) said he was 100% P & T.

That too is part of my past WH complaint.

But then again, there is nothing you can do , until you get the decision.

Except check out the C & P doctor because they might not have even had the credentials needed to opine on this type of C & P exam.That would be a valid point on appeal.

 

 

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1 hour ago, Berta said:

I am rather shocked that you got a copy of this exam so soon.

Have you googled the doctor to see what their credentials are?

I assume this was a VA doctor and not a Contracting doctor- because they usually do not release C & P exams from the contractors until they make a decision.

I received a C & P exam copy that was done posthumously on my husband in 2015, by a VA doctor, not a contractor.

At first I didnt feel I need it ,for years, because I won that cue within a month  after the denial under CUE.

But due to other circumstances, I requested it.

The VA had my sole piece of evidence from the top cardiologist in VACO, DC.

The denial listed it as evidence but it was never considered and my CUE filed the next day immediately reversed the decision.

The C & P I got is so deficient that I filed a White House Hot Line complaint on it last week.

The "examiner" is an internist , who is employed by the VA  and the rhetoric shows she never even looked at the VACO opinion or  (I assume) very few of my husband's medical records.

She also had to write addendum because she first stated this was an "in" person exam.

By time of this exam my husband had been dead for 19 years.

I also requested the third page of a past C & P exam I was present at, done in my husband's lifetime.

A VA Neurologist declared him 100% P & T at that exam.(1151 stroke)The director of my RO told me, he was 100% Total at death but not permanent.That is a ridiculous statement and defies VA case law.All of my medical evidence (to include other evidence from VA, Voc Rehab, Agent Orange Commission, VA doctor signing  student loan waiver ) said he was 100% P & T.

That too is part of my past WH complaint.

But then again, there is nothing you can do , until you get the decision.

Except check out the C & P doctor because they might not have even had the credentials needed to opine on this type of C & P exam.That would be a valid point on appeal.

 

 

@Berta from what I can see on the doctor, he was a neurologist.

And yes, this was a VA doctor. They wanted him to go through a contractor at first and I requested VA only.

It just seems so contradicting...because he didn't check off many symptoms, but he explained a lot of pretty big depression symptoms and then wrote that this is the progression of the major depression...so it is getting worse.

I just don't want them to reduce. I hate this waiting.

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Neuros, without additional expertise in MH issues, should not opine on a depression claim.

https://www.urmc.rochester.edu/highland/departments-centers/neurology/what-is-a-neurologist.aspx

My husband had a VA Neurologist due a C & P exam on him after he had a catastrophic stroke.

His SC PTSD however was opined on by a VA psychologist.

This VA exam seems odd to me. It almost sounds like what I went through-In Feb 2015 the VA called me 4 times.

In one call the VSO or whoecvver he was told me they had alrady "picked" someone to do the C & P.

The someone they picked works at Buffalo in the Agent Orrange Registry program She is also an internist.

It is hard for me to believe she is even a doctor. The exam is ridiculous but it helped them deny that claim. Until I Cued them.

IBut maybe more importantly ,I  think now is the time to get your husband some therapy for his depression from the VA or from a private doctor.

 

 

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2 minutes ago, Berta said:

Neuros, without additional expertise in MH issues, should not opine on a depression claim.

https://www.urmc.rochester.edu/highland/departments-centers/neurology/what-is-a-neurologist.aspx

My husband had a VA Neurologist due a C & P exam on him after he had a catastrophic stroke.

His SC PTSD however was opined on by a VA psychologist.

This VA exam seems odd to me. It almost sounds like what I went through-In Feb 2015 the VA called me 4 times.

In one call the VSO or whoecvver he was told me they had alrady "picked" someone to do the C & P.

The someone they picked works at Buffalo in the Agent Orrange Registry program She is also an internist.

It is hard for me to believe she is even a doctor. The exam is ridiculous but it helped them deny that claim. Until I Cued them.

IBut maybe more importantly ,I  think now is the time to get your husband some therapy for his depression from the VA or from a private doctor.

 

 

@Berta I thought it was a little weird too since his initial C&P in 2013 was done by a psychologist and he was great. Looking a little further it looks like he has some psychology certifications...

I don't know seems weird.

 

I told him the same thing. I let him know that we need to be checking in with the mental health clinic for sure

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The VA  justifies their ratings with documented medical treatment records.

I think their philosophy is, if a veteran has a disability, and they do not get treatment for it, they might not be disabled by it anymore.

I have no idea how they will rate the claim. I am glad you are prepared for a possible lower rating.

 

 

 

 

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55 minutes ago, Berta said:

The VA  justifies their ratings with documented medical treatment records.

I think their philosophy is, if a veteran has a disability, and they do not get treatment for it, they might not be disabled by it anymore.

I have no idea how they will rate the claim. I am glad you are prepared for a possible lower rating.

 

 

 

 

@Berta yea about as prepared as possible. I'm planning on fighting it however we can if we can, if they lower it. It just seems like...they're saying he isn't better, but yet..i don't know.

My thinking would be though that since he's les than a month away from being at 70% for 6 years, that they can't just use this exam to say he's better..and it doesn't say that he IS better anyways! This is just frustrating.

And what else is frustrating is they don't mention what he said as to why he wasn't seeing anyone right now. This is all so crazy.

I really hope they keep him at 70% and don't reduce, but I'm going to fight if they propose to

Edited by AirForceVetsWife (see edit history)
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If they propose a reduction, yes your husband can appeal the decision, in which during that time, they will still have to pay at his current rate. 

Usuaully, once you appeal, these things can drag on for awhile til you get a hearing.

A buudy of mine went through a reduction proposal last yr and it took them 16 months just to decide in his favor.

Edited by Bwaveteran
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11 minutes ago, Bwaveteran said:

If they propose a reduction, yes your husband can appeal the decision, in which during that time, they will still have to pay at his current rate. 

Usuaully, once you appeal, these things can drag on for awhile til you get a hearing.

A buudy of mine went through a reduction proposal last yr and it took them 16 months just to decide in his favor.

That's just so crazy! I mean...I don't know. I get they want to make sure someone isn't getting money for something they don't have. But, this alone puts so much stress on someone. My husband is so anxious now.

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Just have a plan of action and if he has a VSO, if not then get in touch with one as soon as the decision is made.

Then again, he could just remain at that current rate but, I did read his recent exam you posted and the examiner put him in the %50 area but, usually the rater can go up one and keep him at his current rating.

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30 minutes ago, Bwaveteran said:

Just have a plan of action and if he has a VSO, if not then get in touch with one as soon as the decision is made.

Then again, he could just remain at that current rate but, I did read his recent exam you posted and the examiner put him in the %50 area but, usually the rater can go up one and keep him at his current rating.

Just have a plan of action and if he has a VSO, if not then get in touch with one as soon as the decision is made.

Then again, he could just remain at that current rate but, I did read his recent exam you posted and the examiner put him in the %50 area but, usually the rater can go up one and keep him at his current rating.


@Bwaveteran That's what I was thinking because technically in 2013 in his initial C&P they checked the same box, which would be in the 50% category but they rated him at 70%

 

Do you have to have a VSO from your county? We have one here local that he used to talk to...but then he turned out not to be so great and helpful. I work at a doctor's office and we get a lot of vets in from the choice program that speak highly of a certain VSO about an hour away

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