PWHT Registration Form
The International Association of Human Values (
www.IAHV.org
) is a non-profit educational and humanitarian foundation that has provided stress management, humanitarian and trauma-relief programs in the United States and worldwide in areas of trauma, conflict, and natural disaster. THIS FORM WILL BE KEPT CONFIDENTIAL
Sat, Sun Jan 30-31 at 9am - 11:30am PT
Sat-Sun Feb 6-7 at 9am - 12:00pm PT
Mon Feb 8 at 6pm - 8:30pm PT
* Required
Email address
*
Your email
Power Breath Meditation Workshop
First Name
*
Your answer
Last Name
*
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Emergency Contact & Phone
Your answer
Email
Your answer
Occupation
Your answer
Date of Birth (Must be at least 18 years old)
MM
/
DD
/
YYYY
Sex
Choose
Male
Female
Participant Designation
Choose
Military
Family
Significant Other
Service Provider
Branch of Military Service
Choose
Air Force
Army
Coast Guard
Marine Corps
Navy
Military Status
Choose
Active Duty
Veteran
Reservist
National Guard
Retiree
Rank
Your answer
Deployment information (optional)
Your answer
How did you hear about the course?
Your answer
Briefly describe your mental and physical health
Your answer
Please indicate if you have any of these conditions:
*
Asthma
Diabetes
Emphysema
seizures/Epilepsy
Heart Disease
Stroke
Bi-polar
High Blood Pressure
Depression
Dissociative Identity Disorder
Traumatic Brain Injury
Pregnancy
NONE
Required
If you are you presently under the care of a physician, or psychiatrist, or have been recently hospitalized, please describe :
Your answer
Please list any health problems or recent health concerns:
Your answer
Please describe in detail all medications you are taking:
Your answer
Please list dates, course name and experiences with any meditation techniques or other self-development courses/techniques you have done
Your answer
Agreement
It is compulsory to attend all sessions of the course. Taking notes and use of tape recorders is prohibited. Agreement: I understand that any benefits derived from this course depend upon the extent of my participation. I therefore accept full responsibility for the outcome and I willingly agree to follow all instructions and participate fully. I also agree that I will not disclose the content of this course to anyone. I further agree that I will not attempt to instruct others in any of the techniques used in the course until such time as I receive personal training from Project Welcome Home Troops or IAHV. By entering my name and date below I agree to the above.
Signature
Your answer
Today's Date
MM
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DD
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YYYY
Military Stress Checklist
Instructions: Below is a list of problems and complaints that veterans sometimes have in response to stressful life experiences. Please read each one carefully and click the appropriate bubble to indicate how much you have been bothered by that problem in the last month. Please use the following scale: Not at all (1) A little bit (2) Moderately(3) Quite a bit(4) Extremely(5)
Repeated, disturbing memories, thoughts or images of a stressful military experience form the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Relapsed, disturbing dreams of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling very upset when something reminded you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Having physical reactions (e.g. heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Avoid thinking about or talking about a stressful military experience from the past or avoid having feelings related to it?
Not at all
1
2
3
4
5
Extremely
Clear selection
Avoid activities or situations because they remind you of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Trouble remembering important parts of a stressful military experience from the past?
Not at all
1
2
3
4
5
Extremely
Clear selection
Loss of interest in things that you used to enjoy?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling distant or cut off from other people
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling as if your future will somehow be cut short?
Not at all
1
2
3
4
5
Extremely
Clear selection
Trouble falling or staying asleep?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling irritable or having angry outbursts?
Not at all
1
2
3
4
5
Extremely
Clear selection
Having difficulty concentrating?
Not at all
1
2
3
4
5
Extremely
Clear selection
Being “super alert” or watchful on guard?
Not at all
1
2
3
4
5
Extremely
Clear selection
Feeling jumpy or easily startled?
Not at all
1
2
3
4
5
Extremely
Clear selection
A copy of your responses will be emailed to the address you provided.
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