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Warrior PATHH Application - Combat Veterans
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I am an active, retired, or separated combat veteran. Please note: If you select "Yes", then please proceed with the Application. If you select "No", then you are not eligible for the Warrior PATHH Program. There are many other organizations that may fit your needs. Please refer to the National Resource Directory. If this is an emergency, please call 911, or call the National Suicide Prevention Lifeline 1-800-273-8255 available 24hrs/day.* *
Your First Name *
Your Last Name *
Your Street Address *
City of Residence *
State of Residence *
Zip Code of Residence *
Phone Number *
Please use numbers only. No dashes, hyphens or parentheses.
Date of Birth *
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What is your age? *
Gender *
How do you publicly self-identify? *
Marital Status *
Emergency Contact Name and Relationship to Them *
Emergency Contact Phone Number *
What is your current employment status? *
In regards to housing, please choose the response that best represents your personal living situation. *
Please select your annual gross income range. *
Branch of Military Service *
Required
MOS/AFSC/Rate and Description *
Date you ENTERED service as a military member *
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Date you ENDED service as a military member (provide current date if still on active duty) *
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YYYY
How long have you served or did you serve in the military? *
What is your current rank or the rank you achieved prior to leaving service? *
Did you serve in the military after September 11, 2001? *
Choose the selection which best describes your current status *
List military combat deployments *
How many total months have you been deployed to a combat zone? *
Are you now or were you ever a first responder (defined as anyone who has received certification to serve their community as a Police Officer, Sheriff’s Deputy, Corrections Officer, FBI, CIA, U.S. Air Marshal, Marshal Service, EMS/EMT, para-rescue, firefighter, or frontline healthcare worker and has been involved in a critical incident)? *
If you answered Yes to the previous question, please indicate First Responder type below. If answered No to previous question, select NA. *
Required
Were you injured or wounded during your military service? *
If you answered "Yes" to above question, please provide a brief description of nature of injury below. If answered "No" to above question proceed to next question.
Have you been diagnosed with a TBI (Traumatic Brain Injury)? *
Do you or others close to you think that you have emotional or psychiatric difficulties that need to be addressed? *
If you answered "Yes" to above question, please provide a brief explanation below. If answered "No", proceed to next question.
Have you received a psychiatric diagnosis from a behavioral health or medical professional after seeking their help? *
If you answered "Yes" to above question, please provide list of all diagnoses with approximate dates of diagnosis and any treatments received below. If answered "No", proceed to next question.
Rate your level of satisfaction or dissatisfaction with any therapies or treatments you have received. If you have not received any therapy or treatment, please select NA. *
Have you experienced thoughts of suicide within the past year? *
If you answered "Yes" to above, please provide brief explanation of when and what was going on in your life that contributed to your thoughts. If answered "No" to above, please proceed to next question.
Have you ever been hospitalized for psychiatric reasons? *
Are you currently under the care of a mental health or medical professional for your psychiatric condition(s) (e.g., psychologist, psychiatrist, social worker, primary care manager)? *
If you answered "Yes" to above, please give the name of your provider and the nature of the treatments being received currently. If answered "No" to above, please proceed to next question.
Please list the names of any current prescription medications used and what you use them for (put N/A if you have none). *
How much alcohol do you currently drink in one week? *
Are you currently in, or have you ever been in treatment for alcohol or substance abuse? *
If you answered "Yes" to above, please provide brief details on circumstances surrounding treatment and approximate dates of treatment. If answered "No", please proceed to next question.
In regards to drugs and alcohol, please choose the response that best represents your personal situation. *
Have you ever been convicted of a misdemeanor or felony, or do you have a pending felony charge against you? *
If you answered "Yes" to above, please provide brief details on circumstances surrounding incident and approximate dates of charge. If answered "No", please proceed to next question.
Please describe any pending legal responsibility, especially if there is a required physical appearance in court (if none, then put N/A). *
Are you currently undergoing a Medical Evaluation Board or seeking disability compensation from the VA or your employer? *
Select any services you use from the Dept. of Veterans Affairs from below (Select all that apply). If you do not use any VA services, please check the appropriate box related to reason for non-use below. *
Required
Were you referred to Warrior PATHH by someone at the VA? *
What support groups do you attend, or self-help activities/wellness practices do you do? *
Do you have a service, therapy or assistance dog? *
Please list the ways (positive and/or negative) you currently cope with or manage stress. *
Please identify specific people in your life that you rely on for support. Briefly describe how each person supports you. *
Please tell us your personal goals for attending the Warrior PATHH program. What do you hope to achieve or change as part of your work in this program? *
Please describe why you feel that a program like Warrior PATHH will benefit you at this point in your life. *
Please describe what personal characteristics, relationships, work problems or other issues are likely to be obstacles to your ability to implement changes to your daily life. *
Have you participated in any other veteran-specific programs (for example, with Boulder Crest Retreat, GratitudeAmerica, Camp Southern Ground, Travis Mills Foundation, Big Red Barn Retreat, Permission to Start Dreaming Foundation or Wounded Warrior Project, etc.) in the past? Which program(s) and when? *
How did you hear about the Warrior PATHH Program? *
CONFIDENTIALITY: Respect of your right to confidentiality is of the utmost importance to creating an environment of safety and trust. Strict adherence to the confidentiality ethic is a serious matter. This means that we do not say who was here or discuss what they bring up in any aspect of this program with anyone outside of the program either now or after the program is finished. Each person here is a holder of confidentiality for everyone s/he meets here; each person's story is theirs alone to tell and to break this guideline is to breach the trust created in the Boulder Crest community. This includes posting any information about others in the program on social media websites or otherwise sharing the names or personal information of any other participants with others at any point. *
PARTICIPATION: Participants must commit to being part of all training events, group sessions and meals. Please be on time and respect yourself and others. *
No weapons are allowed on the premises, including storing them in vehicles (examples include: guns, knives of any kind, sticks, mace, etc.). *
Cell phones, laptops and tablets will be left in cabins during the day. Cabin televisions may/may not be available for your use, but please respect your cabin mates with your choice of program and volume. PlayStation, XBox and similar systems are NOT PERMITTED. Leave them at home. *
Warrior PATHH is a peer-based training program that relies on a variety of educational and experiential activities for the purpose of teaching life skills, increasing community integration and involvement, and promoting optimal physical, emotional, relational, financial, and spiritual health. Warrior PATHH is not an outpatient or residential clinical treatment program and does not use licensed healthcare professionals in the delivery of programs or supervision of staff. Warrior PATHH does not include individual, group, or family counseling or psychotherapy, pharmacological management, or medical interventions *
I certify that my answers are true and complete to the best of my knowledge. By signing your full name, you are agreeing to the above policies and digitally signing this application. *
Please watch the following video featuring Ken Falke which describes, in part, the Warrior PATHH curriculum and student participation expectations. By signing your name above and submitting this form you acknowledge that you have watched this video and agree to participate in all Warrior PATHH training modules pending acceptance and subsequent assignment to a Warrior PATHH program. If you have any questions regarding the training please address them with your Warrior PATHH recruiter during the admission process. Thank you.
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