NATIONAL VETERANS WELLNESS & HEALING CENTER
2027 PTS Retreat Application
Confidential Application • Please complete all applicable sections
IMPORTANT - PLEASE COMPLETE THE ENTIRE APPLICATION
The information requested in this application is important to our ability to determine whether the NVWHC Retreat Program is appropriate for you and your partner/support person and to help our team prepare to support you safely and effectively.
Please answer every question as completely and honestly as possible.
If a question does not apply to you, please write N/A rather than leaving it blank. Incomplete applications may delay the review process and may be returned for additional information before an applicant can be considered for a retreat.
NVWHC Retreats are not a vacation or recreational getaway.
They are highly specialized, intensive programs designed to help participants better understand trauma, develop healthy coping skills, strengthen relationships, and identify tools that can support continued healing and wellness.
The retreat experience requires active participation, personal commitment, and a willingness to engage in the scheduled program. Some activities may be emotionally challenging. Providing complete and accurate information helps our team determine whether the retreat environment can appropriately meet your needs and allows us to plan for your safety and support throughout the program.
Submission of an application does not guarantee acceptance or a specific retreat date. Each application is reviewed individually.
Before You Apply
* An asterisk indicates required information.
• NVWHC retreats are intensive seven-day programs for eligible Veterans / Active Military / First Responders and their spouse, partner, or support person. The applicant must have a diagnosis of Post-Traumatic Stress (PTS).
• Both participants are expected to commit to the full retreat schedule and participate in scheduled activities and appointments. Retreat locations are above 8,500 feet in elevation.
• Lodging and meals are provided at no cost. Participants are responsible for travel expenses. Children may not attend the retreat.
• Alcohol and recreational drug use are prohibited for the entire retreat. Applicants with recent safety concerns, active substance-use concerns, or significant medical needs may require additional screening before acceptance.
I have read the information above:
Applicant
Partner/Support Person
1. Applicant & Partner / Support Person Information
Applicant legal name*
*
First Name
Last Name
Preferred first name
First Name
Date of birth*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Partner/support person legal name*
*
First Name
Last Name
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Preferred first name
First Name
Date of birth*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to applicant*
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant cell phone*
*
Format: (000) 000-0000.
Applicant email*
*
example@example.com
Partner cell phone*
*
Format: (000) 000-0000.
Partner email*
*
example@example.com
Emergency contact name / relationship
First Name
Last Name
Emergency contact phone
Format: (000) 000-0000.
Have either of you attended an NVWHC retreat before?
No
Who/when details
2. Service Information
Applicant service category*:
*
Veteran
Active Military
Retired Military
First Responder
Other
Branch / agency / type of service*
*
Years of service*
*
Discharge / separation date (if applicable)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rank
*
MOS / AFSC / Rating / Military Specialty
*
Combat zone(s) / duty location(s)
*
Deployment dates
Awards / decorations (optional)
Is the partner/support person also a Veteran, Active Military member, or First Responder?
*
No
Yes
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If yes, branch / agency / type of service
*
Years of service / status
*
MOS / specialty (if applicable)
DD214 or proof of service
Browse Files
Drag and drop files here
Choose a file
Upload: Vets-DD214, Active Duty & First Responders- Service ID Card
Cancel
of
Please include proof of service for the applicant (for example, DD-214, service ID, or other acceptable documentation).
3. PTS, Counseling & Current Safety Information
Applicant PTS diagnosis*
*
Date/year diagnosed*
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / provider*
*
Current or past counseling / behavioral health care*
*
Current counselor/therapist, if applicable
Provider phone/email
Has the applicant experienced Military Sexual Trauma (MST)?
*
No
Yes
Prefer to discuss privately
Has the applicant attempted suicide within the past 6 months?* — Date:
*
No
Date:
Is the applicant currently experiencing thoughts of suicide or self-harm?*
*
No
Yes
If yes to either question above, are you currently working with a licensed mental health professional?
No
Yes
May NVWHC contact that provider as part of retreat screening? Provider/contact:
No
Provider/contact
Partner/support person diagnosed with PTS?
*
No
Yes
If yes, date/year diagnosed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Facility / provider
Current/past counseling
Has the partner/support person attempted suicide within the past 6 months?* — Date:
*
No
Date:
Is the partner/support person currently experiencing thoughts of suicide or self-harm?*
*
No
Yes
Safety Screening
Have you ever been convicted of a violent crime or offense?
*
No
Yes
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If yes, please briefly explain the nature of the offense and approximately when it occurred. This information is requested as part of NVWHC's participant safety and suitability review and does not automatically disqualify you from consideration.
Trauma & Significant Life Experiences
Trauma can result from many different experiences, and more than one experience may contribute to the challenges a person is facing. Please select all that apply to you. You are not required to provide graphic or highly detailed information.
Please select all that apply to you:
Moral injury / moral wounding
Military sexual trauma (MST) / sexual trauma
Military training or service-related trauma
Grief / bereavement / significant loss
Domestic violence / intimate partner violence
Disaster or mass casualty event
Combat-related trauma
Childhood trauma / adverse childhood experiences (ACEs)
Military loss / death of a service member
First responder-related trauma
Traumatic brain injury (TBI)-related challenges
Suicide-related event, loss, exposure, or attempt
Other
Which of the experiences selected above is having the greatest impact on you currently?
Is there anything about the experiences you selected above that you would like our retreat team to know? You may share as much or as little detail as you are comfortable providing.
4. Applicant PTS Symptom Questionnaire
Please answer each item based on how much you have been bothered by the problem during the past month. Select one response for each item.
For the symptom questions below, think about the experience(s) you identified above or the stressful experience currently affecting you most.
When did it occur?
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PTS Symptom Questionnaire
Rows
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, objects, or
situations)?
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?
5. Partner / Support Person Wellness Questionnaire
Your participation is intended to support both you and the applicant. Please answer each item based on your own stressful experiences or overall stress during the past month, even if you have not been diagnosed with PTS.
Stressful experience / primary stressor (optional brief description):
When did it occur?
PTS Symptom Questionnaire
Rows
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, objects, or
situations)?
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?
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Partner/support person: On average, what degree of normal stress/distress do you experience? 0 (none) to 10 (extreme):
6. Medical, Accessibility & Dietary Information
Because retreat locations are above 8,500 feet, please disclose medical conditions or equipment needs that could affect safe participation. Attach an additional medication list if needed.
6. Medical, Accessibility & Dietary Information Because retreat locations are above 8,500 feet, please disclose medical conditions or equipment needs that could affect safe participation. Attach an additional medication list if needed.
Rows
Applicant
Partner / Support Person
Service-connected disability % / condition (if applicable)
Prescription medications and uses*
Heart, lung, or other serious diagnosis*
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Medical equipment / conditions (Applicant)
Diabetes
Oxygen
Nebulizer
CPAP
Other
Medical equipment / conditions (Partner)
Diabetes
Oxygen
Nebulizer
CPAP
Other
Mobility / accommodation needs (Applicant)
Wheelchair
Walker
Cane
Other
Mobility / accommodation needs (Partner)
Wheelchair
Walker
Cane
Other
Allergies / sensitivities
Dietary needs (Applicant)
Vegetarian
Vegan
Gluten-free
Other
Dietary needs (Partner)
Vegetarian
Vegan
Gluten-free
Other
Medical Marijuana: If you use medical marijuana and plan to use it during the retreat, you MUST submit a copy of your valid medical marijuana identification card with your application. Recreational marijuana use is not permitted during the retreat. Marijuana may not be used during the retreat without the required medical authorization/documentation.
Alcohol / non-prescribed or recreational drug use:* Applicant:
*
Partner:
If in recovery, how long? Applicant:
Partner:
ALCOHOL & DRUG POLICY: Alcohol and recreational drug use are prohibited during the entire retreat. Prescribed medications must be used only as directed. Please disclose substance-use or recovery concerns so NVWHC can determine whether additional screening is needed for safe participation.
7. Service Animals
Service animals trained to perform work or tasks for a person with a disability are welcome. Participants are responsible for maintaining control of their service animal. If an animal is out of control and the handler does not take effective action, or the animal is not housebroken, NVWHC may require the animal to be removed from a specific setting while continuing to offer services to the participant when feasible.
Applicant service animal required because of a disability?
No
Yes
Task/work performed:
Partner service animal required because of a disability?
No
Yes
Task/work performed:
Does either participant have a concern about being around dogs?
No
Yes
Explain:
8. Retreat Logistics & Preferences
When available, the retreat may include an equine experience and a gentle horseback ride. Participation is optional. Height and weight information helps the equine provider plan appropriately.
Applicant horseback ride
Yes
No
Height ft.
blanks
Height in.
Type a label
Weight
blanks
Partner horseback ride
Yes
No
Height ft.
blanks
Height in.
Type a label
Weight
blanks
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1)
1st preferred retreat date
2)
2nd preferred retreat date
3)
3rd preferred retreat date
How did you hear about NVWHC?
Current retreat dates are posted at VeteransWellnessAndHealing.org. Availability is limited, and requested dates are not guaranteed.
9. Application Checklist & Submission
Please complete the checklist below:
Entire application completed; N/A entered for questions that do not apply
Applicant PTS symptom questionnaire completed
Partner/support person questionnaire completed
Proof of applicant and/or partner service attached
Both participants reviewed the Participation Agreement and Privacy Notice
Both participants signed the acknowledgment
Mail:
National Veterans Wellness & Healing Center, PO Box 805, Angel Fire, NM 87710
Email scanned application:
retreats@vethealingcenter.org
Questions:
Janice Podell • (575) 377-5236
10. Participation Agreement
NVWHC is committed to providing a safe, respectful environment that supports healing and personal growth. Participation in the retreat is voluntary; however, acceptance into the program requires agreement to the following expectations:
Alcohol & Recreational Drugs:
Alcohol and recreational drug use are prohibited during the entire retreat. Prescribed medications must be used only as directed. Medical marijuana may be used only when medically authorized and when the participant has submitted a copy of a valid medical marijuana identification card to NVWHC. Recreational marijuana use is not permitted. If this policy is violated you will be released from the program immediately.
Cellphones & Mobile Devices:
Phones, tablets, and other devices must be silenced and put away during scheduled activities and appointments unless an exception has been discussed with the Retreat Program Director or Facilitator.
Firearms & Weapons:
Firearms and other weapons are not permitted on retreat property, in lodging spaces, therapy spaces, meeting rooms, dining areas, equine facilities, or other retreat program spaces.
Participation & Punctuality:
Participants are expected to attend scheduled activities and appointments and arrive on time. If illness, a medical issue, or another significant circumstance prevents attendance, notify the Retreat Program Director or Facilitator as soon as possible.
Respect & Confidentiality:
Participants must treat other participants, staff, providers, and guests respectfully. Personal stories or information shared by other participants should not be disclosed outside the retreat without permission.
Program Safety:
NVWHC reserves the right to dismiss a participant whose conduct violates these expectations or creates a safety concern or substantial disruption to the retreat environment.
11. Privacy Notice - Acknowledgment
NVWHC maintains health and personal information related to retreat screening and services. Information may be used or disclosed as permitted or required by applicable law for services, operations, safety, oversight, or other authorized
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purposes. Participants may request information about NVWHC privacy practices and may contact the Center regarding privacy questions or concerns.
Privacy contact:
National Veterans Wellness & Healing Center, PO Box 805, Angel Fire, NM 87710
12. Certification & Signatures
By signing below, we affirm that the information provided in this application is accurate and complete to the best of our knowledge. We understand that submission does not guarantee acceptance or a specific retreat date. We acknowledge the retreat expectations described above and confirm that we have received or been given access to NVWHC's current privacy notice and participation requirements.
Applicant signature*
*
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Partner/support person signature*
*
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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