2024 VETERANS WELLNESS & HEALING RETREAT APPLICATION
PERSONAL INFORMATION -All personal information is confidential and treated according to HIPAA guidelines. Both retreat participants must complete this application TOGETHER. If you are are a SINGLE veteran, simply leave the partner sections blank. Please submit a copy of your DD214 to retreats@vethealingcenter.org Call 505-501-8337 with any questions. You may also download an application and mail to: NVWHC PO Box 805, Angel Fire, NM 87710
Service Member/Veteran Name
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Last 4 digits of SSAN
Ethnicity
Tribal Affiliation
Name of Spouse/ Partner
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Partner Last 4 digits of SSAN
Partner Ethnicity
Partner Tribal Affiliation
Relationship to Veteran
What first name to do prefer to go by? Veteran:
blank
Partner
blank
Veteran Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Children
Ages/Gender
Veteran Email
example@example.com
Veteran Cell Phone
Please enter a valid phone number.
Parner Cell Phone
Please enter a valid phone number.
Partner Email
example@example.com
Veteran Employment Status
Please Select
Full-Time
Part-Time
Retired
Disabled
Unemployed
Veteran Living Situation
Please Select
Homeless
Supportive Housing
Structured Setting
House Owned/Rented
Staying/Living with family/friends
Have you or your partner attended one of our retreats?
Yes
No
If yes, when?
Veteran Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Awards/ Decorations
Current Status
Active Duty
Military Retired
Veteran
Other
Rank
Is your Spouse/Partner a military veteran? If so, please provide the following
Yes
No
Partner Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Awards/ Decorations
Current Status
Active Duty
Military Retired
Veteran
Other
Rank
Veterans PTS was diagnosed: Date/Year
What VA Facility?
If not VA, what Clinic or Professional Health Care Provider?
Current/ Past Counseling:
Has Veteran experienced Military Sexual Trauma?
Yes
No
If so, when?
Has the Spouse/Partner been diagnosed with PTS?
Yes
No
PTS was diagnosed: Date/Year
What VA Facility?
If not VA, what Clinic or Professional Health Care Provider?
Current/ Past Counseling
Has Spouse/Partner experienced (Military) Sexual Trauma?
Yes
No
If so, when?
Veteran Participant Name
First Name
Last Name
Veteran Instructions: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully and then check one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Make sure to case your answers on problems that started or got worse after the event. The event you experienced was
(Name event) in Month/Year when event occurred). Indicate how much were you bothered by each item in the last month. As a guide: Extremely might mean almost every day; Quite a Bit might mean 20 days out of the past 30; Moderately might mean 10 to 14 days; and a Little Bit might mean any number of days less than 10 days out of the last 30. IF you were not bothered but he indicated problem at all during the last 30 days; select Nat at All.
VETERAN PTS SYMPTOM QUESTIONNAIRE in reference to the last 30 days
Not At All
A Little Bit
Moderately
Quite a Bit
Extremely
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, or objects)
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?
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 (who didn't directly cause the event or actually harm you) 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. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Feeling irritable or angry or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being "super alert" or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?
Partner/Support Person Name
First Name
Last Name
The purpose in having you to join your veteran is not only for you to help provide support and healing to them, but to also provide a healing opportunity for you. Our focus throughout the retreat will be to meet the needs of both you and your partner equally. To help us do this, we would like to understand the degree to which you might be experiencing symptoms of stress in your life whether the symptoms result from your own history or trauma, the normal stresses of life, or from your relationship with someone who has PTS. Please answer the two questions below, and complete the PTS questionnaire. Where the questionnaire uses the term "the stressful experience", you may answer according to a specific experience you have hasor to the overall stress you experience in your life. Before completing the questionnaire, please answer the following questions: 1. On average, to what degree do you experience normal stress/distress? 0-10 (0=none; 10=extreme)
2. Have you had an experience(s) where you felt your ethics (your send of right and wrong) was strongly violated, resulting in a significant send of self blame, shame, confusion, anger/rage or depression?
Partner Instructions: Below is a list of problems and complaints that people sometimes have in response to stressful life experiences. Please read each one carefully and then check one of the numbers to the right to indicate how much you have been bothered by that problem in the past month. Make sure to case your answers on problems that started or got worse after the event. The event you experienced was
(Name event) in Month/Year when event occurred). Indicate how much were you bothered by each item in the last month. As a guide: Extremely might mean almost every day; Quite a Bit might mean 20 days out of the past 30; Moderately might mean 10 to 14 days; and a Little Bit might mean any number of days less than 10 days out of the last 30. If you were not bothered but he indicated problem at all during the last 30 days; select Not at All.
PARTNER/ SUPPORT PERSON PTS SYMPTOM QUESTIONNAIRE in reference to the last 30 days (Please complete even if you have not been diagnosed with PTS)
Not At All
A Little Bit
Moderately
Quite a Bit
Extremely
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, or objects)
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?
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 (who didn't directly cause the event or actually harm you) 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. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
15. Feeling irritable or angry or acting aggressively?
16. Taking too many risks or doing things that could cause you harm?
17. Being "super alert" or watchful or on guard?
18. Feeling jumpy or easily startled?
19. Having difficulty concentrating?
20. Trouble falling or staying asleep?
Veterans Service connected disability %
Condition/Basis
Prescription Medication and their uses
Veteran
Do you have any lung or heart issues or a serious medical diagnosis?
Unprescribed/illegal/drug/alcohol use. What substance(s) and how much/how often?
If you are in recovery, how long? (All retreat participants must be free of any drug/alcohol addictions for at least 12 months prior to attending)
Physical conditions that require assistance/unique accommodations
Motorized Wheelchair
Wheelchair
Walker
Cane
Other
Medical Conditions
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment
Other
Sensitivities or allergies
Smoke
Other
Dietary
Vegetarian
Vegan
Gluten Free
Other
Does Veteran have an issue being around dogs?
Yes
No
Does Veteran have a Service Dog that is required because of a disability?
Yes
No
What work or task has the dog been trained to perform?
Partner Service connected disability %
Condition/Basis
Prescription Medication and their uses
Partner
Do you have any lung or heart issues or a serious medical diagnosis?
Unprescribed/illegal/drug/alcohol use. What substance(s) and how much/how often?
If you are in recovery, how long? (All retreat participants must be free of any drug/alcohol addictions for at least 12 months prior to attending)
Physical conditions that require assistance/unique accommodations
Motorized Wheelchair
Wheelchair
Walker
Cane
Other
Medical Conditions
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment
Other
Sensitivities or allergies
Smoke
Other
Dietary
Vegetarian
Vegan
Gluten Free
Other
On occasion there are service dogs that attend retreats. Do you have any issues being around dogs?
Yes
No
Does Partner have a Service Dog that is required because of a disability?
Yes
No
What work or task has the dog been trained to perform?
We conduct and equine experience on the 5th day of the retreat followed by a very mellow horse back rideVeteran Horse Back Ride. Please indicate if you would like to participate in the ride Veteran Horse Back Ride
Yes
No
Partner Horse Back Ride
Yes
No
Are you are a single veterans who has no partner, but would be willing to partner with another single veteran, please indicate:
Yes
No
2024 Retreat Dates, Please Indicate your first and second choices of times to attend
April 28- May 5
June 2-9
August 18-25
October 20-27
How did you hear about NVWHC?
Please email a copy of your DD214 to retreats@vethealinjgcenter.org
We have read the entire application and believe all of the answers given are true and correct. Signature of Service Member/Veteran
Signature of Spouse/Partner
Date
-
Month
-
Day
Year
Date
Thank you for your interest in our retreats! Once your application has been processed, you will be contacted regarding availability. Please call 505-501-8337 or email retreats@vethealingcenter.org for questions. For a copy of our Privacy Practices and Retreat Participation Agreement, please see downloadable application on website.
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