Intake Form

PROGRAM OVERVIEW

Mandatory Commitment for Full Recovery
While our program includes a gym membership, it's important to understand that this is not merely a free gym pass. The core purpose of WarriorWOD's "Exercise as an RX" program is to facilitate your recovery from Post-Traumatic Stress and other invisible wounds.

Your active participation and communication in this program is not optional—it's essential for your path to recovery. We're here to support you, but you must meet the following requirements to be successful in the program:

Communication: Effective and timely communication to the WarriorWOD team.

Sponsored Gym Visits: Commit to a minimum of two sponsored gym visits per week. Additional exercise is encouraged.

Nutrition Coaching: Engage in bi-weekly meetings with your nutrition coach. Daily food logs via the MyFitnessPal app. Completion of an Inbody Scan within the first two weeks of the program.

Battle Buddy Meetings: Engage in bi-weekly meetings with your battle buddy.

Program Progression Survey: Complete a monthly survey to assess your progress.

Each component is integral to maximizing the impact on reducing your Post-Traumatic Stress. Communication of any barriers that may prevent you from completing one or more of these requirements during the program is expected so we may work with you.

You must subscribe to our newsletter otherwise, you will not receive a notification if approved.
PERSONAL INFORMATION
Name*

First NameLast Name
Preferred Name*
Email*
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState (Abbreviate)

Zip CodeCountry
Birthdate*

YearMonthDay
Race*
Gender*
Pronouns*
Relationship Status*
Are you currently employed?*

YesNo
If not employed, are you able to work?*

YesNo
If yes, what is your occupation?*
If you are not employed, is it because of medical problems related to your military service*

YesNo
How did you learn about WarriorWOD? Answering this allows us to be found by other veterans that need our help. *
Battle Buddy Gender Preference*
Although we cannot guarantee your preference, we will do everything we can to accommodate.
What size T-Shirt do you wear?*

EMERGENCY CONTACT INFORMATION
Emergency Contact Name*

First NameLast Name
Emergency Contact Email*
example@example.com
Emergency Contact Phone Number*
Relationship to You: *
Example: Partner, Friend, Relative.

INFORMATION RELATED TO SERVICE
Please attach a copy of your discharge form, DD Form 214. You must black out all social security numbers. Failure to do this will automatically disapproval of your package. *

Cancelof
What branch of Service? *
Initial Date of Entry*

YearMonthDay
End of Service*

YearMonthDay
Please state your type of discharge**
Were you in combat? Were you a recipient of Hostile Fire Pay or Imminent Danger Pay*

YesNo
Are you a Purple Heart Recipient*

YesNo

SPONSORED GYM INFORMATION
Please provide all information regarding your preferred gym for this program below. Information must be for the gym owner or manager.

We highly recommend that you find a gym with group classes. Gyms such as the following, but not limited to, do not qualify for this program: Anytime Fitness, Crunch, 24hr Fitness and Planet Fitness.

Finding the right fit for you is VERY important. Consider gym amenities, operation hours, distance to your home, community/culture, noise level, what style of exercise you prefer, phyisical limitations, and communication.

You are responsible for initiating communication with the gym of your choice to explain the program and provide owner/manager contact information. A program flyer is provided in this application. If selected for the program, the gym owner/manager must reply to emails from WarriorWOD.
Please provide this to the gym you would like to use during the program*
Gym Name*
Gym Website*
Gym Address (Street, City, State, Zip)*
Manager Name*
Manager Email*
example@example.com
Manager Phone Number*
Have you visited the gym yet?*

YesNo
Gym Membership Monthly Cost (number).*
How much is the Monthly Cost (Ask for Veteran Discount)
Have you been in contact with the owner/manager?*

YesNo

Do we have consent to share the General Health section with your gym owner, nutrition coach and battle buddy? By checking the boxes below and initial below, you are consenting. (only this section will be shared)*

YesNo
We will use this data to track progression of participants throughout of program. By checking yes and providing your initials below, you are agreeing that we can use your responses to demonstrate program effectiveness. All Personal Protective Information will be removed.*

YesNo
Initials*
If you are satisfied with your application, please sign below. Thank you for your interest in joining the WarriorWOD Tribe! *

Clear

Unfortunately, you are not eligible for this program.

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	YES	NO
Did you experience a stressful event related to your hostile fire while deployed in a combat zone?
Do you have recurring dreams or intrusive memories about combat or hostile military activities?
Do you have recurring dreams or intrusive memories about any traumatic experience during military service (one that involved feelings of intense fear, helplessness, or horror?
Do you avoid, or react unusually to, things that symbolize or remind you of a traumatic event from your time in the service
Has a medical professional or mental health expert (a doctor or a psychologist, for example) diagnosed you with PTSD?
Has a doctor told you that your PTSD was caused by your service?
Were you personally assaulted during service (personal assault includes but not limited to, rape, physical assault, domestic battering, robbery, mugging, and/or stalking)?

	0	1	2	3	4
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. 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)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?
14. Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Irritable behavior, angry outburst, or acting aggressively?
16. Taking too many risk or doing things that could cause you harm?
17. Being "superalert" or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?

WarriorWOD Application

Unfortunately, you are not eligible for this program.