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GENERAL INFORMATION

Participants should arrive at the Guardian Hills Campus between the hours of 2:00 PM and 4:00 PM on the Sunday beginning the retreat. Travel will be paid by the participant. The Retreat does not cover any travel expenses. Retreat activities, lodging and meals will be provided at no cost to the participants. A list of recommended supplies, clothing, etc., as well as other detailed information will be forwarded to participants prior to the scheduled Retreat.

For questions related to the Retreats and/or the Retreat Application process, please call us at: 573-530-9292: or email: info@guardianhills.com. 

Once your application has been received and processed, you will be notified and placed in one of our first available scheduled retreats. See the Guardian Hills webpage (www.guardianhill.com) for retreat schedule. If circumstances require a particular retreat start date, please indicate below. 

Availability is limited.

Typically, there are 12 Retreats per year (2 per month May - October)

Once your application has been received, we will call you to discuss dates and details. Mail the entire completed Retreat Application to:

Guardian Hills Veterans Healing Center
Attn: Applications
1302 Morning Dove Drive
Columbia, MO 65201

Email scanned applications to info@guardianhills.com
**Please include a copy of your DD-214 with your application.

I have read the entire application and believe all of the answers given on the Retreat Application are true and correct.

I have also read the Center’s health information privacy practices available online.

Date: October 10, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Emergency Contact's Relation to Participant
DD-214 UPLOAD
Click to customize text box label
  
Valid file types: JPG, GIF, PNG, and PDF
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Please indicate your first(1) and second(2) choices of times to attend:
MAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
TYPE first and second choices: (Example: September (1st) October (2nd))
How did you hear about Guardian Hills?
Last 4 digits of SSN
Ethnicity
Tribal Affiliation?
What first name do you prefer to go by
Marital Status*
Current Living Situation*
Do you have Children?*
No
Yes
If so, how many?
Ages
Have you attended any other retreat programs?*
No
Yes
If yes, when/where

SERVICE INFORMATION

Branch of Service*
Service Years*
Discharge Date*
Discharge Type H/OTH
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:**
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:*
Is your Spouse/Partner a military veteran?* *
No
Yes
N/A

If yes, please provide the following:*

Branch of Service
Service Years
Discharge Date
Combat Zone(s)
Deployment Dates
Name of MOS/AFSC
Current Status:*
Active Duty
Military Retired
Veteran
Other:
Other:
Rank:

POST TRAUMATIC STRESS (PTS) INFORMATION

If you have been diagnosed with PTS: Date/Year*
If at a VA facility, which one?
If not through the VA, by which Clinic or Professional Provider
Current/Past Counseling:*
Have you experienced Military Sexual Trauma?*
No
Yes
If yes, when and have you received any treatment
Has your Spouse/Partner been diagnosed with PTS? *
No
Yes
PTS was diagnosed: Date/Year
What VA Facility?
If not the VA, what Clinic or Professional Provider?
Current/Past Counseling:
Has spouse/partner ever experienced (Military) Sexual Trauma?*
No
Yes
If yes, when

VETERAN PTS SYMPTOM QUESTIONNAIRE

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 the box to the right to indicate how much you have been bothered by that problem in the past month. As a guide: Extremely might mean every day. Quite a Bit may mean 20 out of the last 30 days. Moderate may be 10 to 14 days. A Little Bit may be 10 days out of the month. If you have not been bothered by the described problem or complaint, mark Not At All.

1. Repeated, disturbing, and unwanted memories of the stressful experience? *
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
2. Repeated, disturbing dreams of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
4. Feeling very upset when something reminded you of the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
6. Avoiding memories, thoughts, or feelings related to the stressful experience?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
8. Trouble remembering important parts of the stressful experience (for some reason besides a head injury or alcohol or drug use)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
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?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
12. Loss of interest in activities that you used to enjoy?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
13. Feeling distant or cut off from other people?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
14. Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
15. Feeling irritable or angry or acting aggressively?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
16. Taking too many risks or doing things that could cause you harm?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
17. Being “super alert” or watchful or on guard?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
18. Feeling jumpy or easily startled?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
19. Having difficulty concentrating?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely
20. Trouble falling or staying asleep?*
Not At All
A Little Bit
Moderately
Quite A Bit
Extremely

MEDICAL INFORMATION:

*Service connected disability %
Condition/Basis

*Prescription Medications and their uses (attach list if necessary):
*Do you have any lung or heart issues or a serious medical diagnosis?

*Unprescribed/illegal/recreational drugs, alcohol and/or tobacco use. What substance 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:
Are you an amputee? If so, which extremity(ies) and level(s)
Motorized Wheelchair
Wheelchair
Walker
Cane
Other:
Other:
*Medical Conditions:
Diabetic
Oxygen
Nebulizer
CPAP or other similar equipment.
Other Medical Conditions:
Other Medical Conditions:
*Sensitivities or Allergies:
Smoke
Other:
Other:
Dietary:
Vegetarian
Vegan
Gluten Free
Other:
Other:

We will do our best to accommodate your dietary needs, but please let us know in advance if you require anything special. All meals are taken together in the main dining facility.

On occasion there are service dogs that attend the retreats. Do you have any issues being around dogs?*
No
Yes
Comments:
*Do you have a Service Dog that is required because of a disability? *
No
Yes
What work or task has the dog been trained to perform?

(Please note: "We welcome your well-behaved service animal. Please understand, however, that we cannot allow unruly dogs to disrupt our mission of providing services to our veterans. In the event your service dog misbehaves or becomes unruly, we will have no choice but to ask you to remove the dog from the premises/situation/room/etc.

Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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