Hero's Compass: Mountain Retreat Participant Application

Hero's Compass: Mountain Retreat Participant Application
Hero's Compass: A Journey of Resilience and Recovery

DTCare is proud to offer Hero's Compass, an 8-day in person adventure counselling retreat followed by an online support program, designed to support transition from military service to civilian life. This program focuses on mental health and well-being, fostering resilience and equipping you with the tools you need to thrive.

What to Expect:

This online form is your first step towards joining the Hero's Compass program but does not guarantee automatic enrollment. Please complete all sections to the best of your ability. Filling out the form allows us to learn more about you and your needs. We aim to accommodate as many veterans as possible while prioritizing safety and therapeutic effectiveness.

Timeline:

Participants will be notified of their acceptance or waitlist status within 2 weeks of the session start. Notification will be made via the email address provided in the application and/or Signal provided in this form.

About the Program:

Hero's Compass is an 8-day adventure counselling program held in the breathtaking Carpathian Mountains of Ukraine. The program will be facilitated by a team of experts including program manager, art-therapist, veteran-mentor, and experienced adventure guides.

Sample Activities:
- Team-building exercises
- Hiking and nature exploration
- Rafting/Kayaking
- Relaxation techniques like meditation or yoga
- Campfire discussions and storytelling, and other
Following the 8-day program, you will be invited to participate in an online support group. This online space allows you to connect with your cohort, share experiences, and receive ongoing support from our professionals.

Primary Communication:

Please note: For the duration of the program, including pre-program arrangements and the online support program, the primary mode of communication will be through the Signal app. We require all participants to have Signal downloaded and available on their personal device. If you are unable to use Signal, please contact us at compass@dtcare.org to discuss alternative arrangements.

Confidentiality:

DTCare is committed to protecting your privacy. All information you share in this application will be stored securely in a confidential database and will not be used or disclosed for any purposes outside of the Hero's Compass program.

Ready to Begin?

Please take your time and answer all questions thoughtfully. If you have any questions about the program or the application process, please don't hesitate to contact us at compass@dtcare.org.

We look forward to hearing from you and potentially welcoming you to Hero's Compass!
Personal Details
Full Name*

First NameLast Name
City/Village/Region*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Country CodePhone Number
Signal Username or Phone Number*
E-mail*
Birth Date*

DayMonthYear
Date
Gender*
T-Shirt Size*
How did you learn about the program?*

Hero’s Compass social media (Facebook, Instagram)Word of mouth (from other veterans or community members)Through a veterans’ organizationThrough other organizationOnline search or websiteOther
Please specify the name of the organization where you learned about the program.
Have you participated in similar programs*

YesNo
If so, which ones?
Do you represent an organization?*

YesNo. Not affiliated with an organization.
Please specify the name of the organization you represent.
General Details and Needs
If selected, which weeks are you available to attend the IN PERSON session..

August 27 - September 3, 2024September 3 - September 10, 2024
What accommodations will be needed while you are at the lodge?*

Mobility: If additional support, such as canes, walking sticks, or access to easier paths, would make your outdoor experience more comfortable, please let us know. We can provide options to suit your preferences.Vision: Would you find descriptive instructions, large print materials, or other resources helpful during activities?Hearing: If visual cues or assistive listening devices would enhance your group activity experience, please inform us.Dietary Needs: Do you have any dietary restrictions (vegetarian, vegan, gluten-free, etc.) that we should be aware of?Triggers: Are there any specific activities or situations that could be potential triggers for you? Knowing in advance can help us plan accordingly.Medications: Please advise if you require safe storage and access to medications during the program.Accessible facilities: Do you require accessible restrooms or sleeping quarters?NoneOther
Please explain the nature of the accommodation needed and what is required.
Do you have a trained service animal? (no emotional support animals)*

YesNo
If Yes, Please provide the following information about this service animal: Breed, weight, size. What work or task has the dog been trained to perform? Note: For safety, service animals cannot be left unattended.
What type of rooming do you prefer for the in-person session?*

Solo RoomRoommateNo Preference
Military Experience
Which Military Branch did you serve?*
In which military unit did you serve?*
What is your military rank? *
What was your job in the military?*
How long did you serve in the military?*
What is your call-sign?*
Activities

Please note: The activities listed are examples and may vary depending on the group's interests and abilities.The best outcomes are achieved when the entire group is fully engaged in the activities.Participation is always a Challenge by Choice, which gives you the power to determine to what level you want to participate in an activity, share in discussions, and the level of challenge you're comfortable with. We prioritize your comfort and well-being throughout the program.
Can you Swim*

YesNo

On a scale of 1-5, rate your comfort level for the following activities. *

	1 - Not Comfortable	2 - Somewhat Not Comfortable	3 - Neutral	4 - Somewhat Comfortable	5 - Very Comfortable
Hiking
Bicycling
Rock Climbing
Water Activities
Yoga

What types of hobbies do you enjoy?*
Have you ever participated in Art Therapy?*

YesNoUnsure
If yes, briefly describe your experience with Art Therapy?
Do you play an instrument?*

YesNo
If yes, what type of instrument do you play?
Do you have any concerns about motion sickness?*

YesNo
Do you have any concerns about altitude sickness?*

YesNo
Are you able to comfortably walk long periods of time (ie. 2+ hours)?*

YesNo
Physical Health and Wellness
Current state of health*
Height*
Weight*
Do you have any recent or current injuries?*

YesNo
Please provide additional information about your injury and needs. *
Do you take any medications on a regular basis?*

YesNo
Please provide additional information about your medications and needs.*
Have you experienced a Traumatic Brain Injury (TBI)*

YesNo
If yes, what related symptoms do you experience?

SeizuresMigrainesMemory LossOther
Describe the nature of your symptoms. Triggers? Frequency? Treatment received? How long do the symptoms last?
Do you have any need or limitations related to the following:*

Spinal InjuryTraumatic Brain Injury (TBI)Hearing/Vision ImpairmentChronic Pain/IllnessProstheticsCane/Walker/WheelchairCPAPDiabetesAsthmaNoneOther
Describe the nature of your needs.
Do you have any upcoming surgeries between now and the sessions starting?*

YesNo
Describe the nature of the upcoming surgery.
Do you have any allergies?*

Airborne: Pollen, Dust Mites, Pet Dander, Mold and MildewSkin: Nickel, Latex, Fragrances, Cleaners, PlantsMedication: Sulfa drugs, Penicillin, NSAIDsFood: Milk, Eggs, Fish, Crustacean Shellfish, Tree Nuts, Peanuts, Wheat, and SoybeansNo Known AllergiesOther
Describe the nature of your allergy and the reaction you experience.
Do you carry an EpiPen?

YesNo
Do you have any food sensitivities or preferences (i.e. vegetarian)? Please describe in detail. *
Emotional Health and Wellness
Who do you live with? What familial supports do you have in your life?*
What networks of support do you have in place currently?*

Individual CounselingCouples/Family CounselingGroup CounselingMental Health CareCommon Interest GroupFamily SupportCommunity SupportFriend SupportWork SupportSupport GroupMedication Management GroupClinical CareChurch/Faith CommunityPeer Support GroupVeteran Service Organization SupportNon-Traditional CareNo Support SystemOther
What is the frequency you are receiving mental health care?
What type of non-traditional care are you receiving?
What type of clinical care are you receiving/have received? (ie In Person, Intensive Outpatient, Partial Hospitalization, Residential)
Do you have current struggles or a history withsubstance abuse and/or alcohol?*

YesNo
Describe the nature of your history with substance abuse.
Do you have current suicidal ideations?*

YesNo
Have you experienced Military Sexual Trauma?*

YesNo
What are your reasons for seeking assistance?*

Work IssuesSocial TriggersRecent LossRelocationAnniversariesMarital Conflict/DivorceTransitioningFamily IssuesConnection/CamaraderieOther
Which of these symptoms impact your day-to-day life?*

StressAnxietyPanic AttacksIntrusive ThoughtsRacing ThoughtsImpulsivityIrrabilityAggression/ViolenceNightmaresDecreased interest in activitiesAvoidanceIsolationDepressionParanoiaFlashbacksDelusionsHallucinationsMemory ConcernsSeizure DisorderSpeech ProblemsChronic PainVision IssuesHeadachesChanges in HearingDizziness/BalanceSensitive to Light/NoiseInformation Processing IssuesGuiltCompassion FatigueMoral InjuryEmotional NumbingGrief/LossCannot Focus/Concentrate on IssuesInability to cope with emotionMoodswings lasting hours or daysHospitalization in the past 2 years
Describe how your symptoms impact your day-to-day life (motivations, school, work, family etc.)?
When a topic comes up that you feel strongly about, how do you express your opinion? If you disagree with someone?*
Do you tend to contribute through active participation or listening?*
How do you feel about sharing your feelings or experiences in a group environment?*
What are you hoping to gain by participating in this program? (8 days in person and online support)*
What are you interested in trying?*
What are you hoping to get out of this experience?*
What do you want the team to know?*
Emergency Contact Information

Please select someone who is not accompanying you on this trip. Note that we will also contact this person if we are unable to get in touch with you about last minute information related to your trip.
Full Name*

First NameLast Name
Phone Number*

Country CodeArea CodePhone Number
Relationship*
DTCare's 8-day in person adventure counselling retreat Hero’s Compass, followed by an online support program

Long-term online support after the retreat: This aspect plays an important role in the rehabilitation process as it provides ongoing accompaniment and support to veterans while they adjust to daily life after the program. This provides a stable platform for recovery and integration into society.

Psychological counseling: Psychological support is crucial for veterans facing post-traumatic stress disorder (PTSD) and other psychological issues. The opportunity to receive counseling from a psychologist throughout their rehabilitation helps veterans overcome challenges and develop coping strategies.

Free Legal Aid: Veterans often need help with legal issues related to benefits, medical payments, employment, starting own businesses, non-profits, or other aspects of their rights. Providing free legal assistance from DTCare ensures that veterans have the support and advocacy they need.

Our programs not only assist veterans in recovering from service, but also demonstrate the importance and concern for their well-being and successful reintegration into society.
Upon request from facilitators, the participant is obligated to submit an official document verifying their veteran status

I confirm my agreement to provide a document verifying veteran status if requestedI do not confirm my agreement to provide a document verifying veteran status if requested
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Hero's Compass: Mountain Retreat Participant Application

Personal Details

General Details and Needs

Military Experience

Activities

Physical Health and Wellness

Emotional Health and Wellness

Emergency Contact Information

DTCare's 8-day in person adventure counselling retreat Hero’s Compass, followed by an online support program