Warrior PATHH Application - Combat Veterans
Email *
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 Name (as appears on government issued ID) *
Your Mailing Address (Street Address, City, State, Zip Code) *
Phone Number *
Year of Birth *
How do you publicly self-identify?
Clear selection
Branch of Military Service (i.e. USA, USMC...) *
MOS/AFSC/Rate and Description *
Date you ENTERED service as a military member *
Choose the selection which best describes your current status *
Date you ended service as a military member (type N/A if still on active duty) *
How long have you served or did you serve in the military? *
Did you serve in the military after September 11, 2001? *
List military deployments, dates, and roles (i.e. Desert Storm, Desert Shield, Gulf War, Kosovo, OEF, OIF, Operation New Dawn, Operation Restore Hope, Panama, Vietnam, or Other). *
Are you 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)? *
Sex *
Marital Status *
Emergency Contact Name and Relationship to Them *
Emergency Contact Phone Number *
Who do you live with?
In regards to housing, please choose the response that best represents your personal living situation. *
What is your current employment status/ *
In regards to sustainable sources of income, please choose the response that best represents your personal financial situation. *
Were you injured or wounded during your service (explain what, when and where)? *
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 (explain)? *
Have you received a psychiatric diagnosis from a behavioral health or medical professional after seeking their help (list all diagnoses with dates you were diagnosed)? *
Have you ever been treated for this diagnosis/diagnoses? If yes, please list all treatments/therapies received. If no, explain why you did not seek help. *
Describe your satisfaction or dissatisfaction with any therapies or treatments you have received. *
Have you experienced thoughts of suicide within the past year? If yes, please describe when and what was going on in your life that contributed to your thoughts. *
Have you ever been hospitalized for psychiatric reasons (explain)? *
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 (explain)? *
In regards to drugs and alcohol, please choose the response that best represents your personal situation. *
Have you ever been convicted of a misdemeanor, felony, or do you have a pending felony charge against you? (If yes, please explain) *
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 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 yes, please give the name of your provider and the nature of the treatments being received currently. *
Please list the names of your medications and what you use them for (put N/A if you have none). *
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. *
Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then indicate how much you have been bothered by that problem in the past month.
In the past month, how much were you bothered by: Repeated, disturbing, and unwanted memories of the stressful experience? *
Repeated, disturbing dreams of the stressful experience? *
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)? *
Feeling very upset when something reminded you of the stressful experience? *
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)? *
Avoiding memories, thoughts, or feelings related to the stressful experience? *
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? *
Trouble remembering important parts of the stressful experience? *
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? *
Blaming yourself or someone else for the stressful experience or what happened after it? *
Having strong negative feelings such as fear, horror, anger, guilt, or shame? *
Loss of interest in activities that you used to enjoy? *
Feeling distant or cut off from other people? *
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? *
Irritable behavior, angry outbursts, or acting aggressively? *
Taking too many risks or doing things that could cause you harm? *
Being “superalert” or watchful or on guard? *
Feeling jumpy or easily startled? *
Having difficulty concentrating? *
Trouble falling or staying asleep? *
Please read the statements below and indicate how much the statement applied to you OVER THE PAST WEEK. There no right or wrong answers. Do not spend too much time on any statement.
I was aware of dryness of my mouth. *
I couldn't seem to experience any positive feeling at all. *
I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness in the absence of physical exertion). *
I found it difficult to work up the initiative to do things. *
I experienced trembling (e.g. in the hands). *
I was worried about situations in which I might panic and make a fool of myself. *
I felt that I had nothing to look forward to.* *
I felt down-hearted and blue. *
I felt I was close to panic. *
I was unable to become enthusiastic about anything. *
I felt I wasn't worth much as a person. *
I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat). *
I felt scared without any good reason. *
I felt that life was meaningless. *
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, or Wounded Warrior Project, etc.) in the past? Which program(s) and when? *
How did you hear about the Warrior PATHH Program? *
Were you referred to Warrior PATHH by someone at the VA? *
In questions to follow, you will be considering your most stressful or traumatic experience. Indicate what kind of experience this was. *
Some events that people experience are so powerful that they "shake their world" and lead them to seriously examine core beliefs about the world, other people, themselves, and their future. Please reflect upon your most stressful or traumatic experience and indicate the extent to which it led you to seriously examine each of the following core beliefs.
Because of my experience, I seriously examined the degree to which I believe things that happen to people are fair. *
Because of my experience, I seriously examined the degree to which I believe things that happen to people are controllable. *
Because of my experience, I seriously examined my assumptions concerning why other people think and behave the way that they do. *
Because of my experience, I seriously examined my beliefs about my relationships with other people. *
Because of my experience, I seriously examined my beliefs about my own abilities, strengths and weaknesses. *
Because of my experience, I seriously examined my beliefs about my expectations for my future. *
Because of my experience, I seriously examined my beliefs about the meaning of my life. *
Because of my experience, I seriously examined my spiritual or religious beliefs. *
Because of my experience, I seriously examined my beliefs about my own value or worth as a person. *
Indicate for each of the statements below the degree to which the change occurred in your life as a result of your most stressful or traumatic experience using the following scale. I changed my priorities about what is important in life.
I changed my priorities about what is important in life. *
I have a greater appreciation for the value of my own life. *
I developed new interests. *
I developed new interests. *
I have a greater feeling of self-reliance. *
I have a better understanding of spiritual matters. *
I more clearly see I can count on people in times of trouble. *
I established a new path for my life. *
I have a greater sense of closeness with others. *
I am more willing to express my emotions. *
I know better that I can handle difficulties. *
I am able to do better things with my life. *
I am better able to accept the way things work out. *
I can better appreciate each day. *
New opportunities are available which wouldn't have been otherwise. *
I have more compassion for others. *
I put more effort into my relationships. *
I am more likely to try to change things which need changing. *
I have a stronger religious faith. *