Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Service Status *

Active

Veteran

Are you currently serving as a Law Enforcement Officer or Fire Fighter?

Yes

No

Did you serve in a combat zone(s)?

Yes

No

Have you been diagnosed with, experienced symptoms of, or been treated for post-traumatic stress (PTSD)?

Yes

No

Are you currently in treatment/therapy/counseling?

Yes

No

Are you taking any prescription medications for medical and/or mental health condition(s) such as PTSD, TBI, etc.?

Yes

No

Do you have a service dog?

Yes

No

Did the trauma occur during your military service?

Yes

No

Have you been diagnosed with, experienced symptoms of, or been treated for traumatic brain injury (TBI)?

Yes

No

Are there medical conditions, allergies (including food allergies) or medications of which we should be aware? *

Yes

No

Have you completed a treatment program for alcohol and/or drugs? *

Yes

No

If you have a history of alcohol and/or drug dependence, are you currently clean and sober?

Yes

No

How did you find out about these retreats? *

If no of those below please identify.

Brochure

Poster Flyer

Website

Veterans Helping Veterans Group

Veterans Organization

VA

Vet Center

A Veteran

A Law Enforcement Officer or Fire Fighter

Other, including referral

Today's Date *

MM

DD

YYYY