The Restorative Path

First name

Last name

Preferred Name (if different):

Date of Birth

Phone Number

Email

Home Address

Emergency Contact Information:

Full Name

Emergency Contact phone number

Demographics and Background

Military Service: Please answer these questions if you served in the military.

Are you a veteran or currently serving in the U.S. Armed Forces?

Yes

No

Military Years of Service:

Military Rank at discharge:

In the military, did you serve in combat or a war zone?

Yes

No

Brief description of military deployment(s)

First Responder Experience: Please answer these questions if you are or have served as a first responder.

Are you a first responder or have you served as a first responder?

Yes

No

Are you currently a first responder?

Yes

No

How many years have you/did you serve as a first responder?

If yes: What roles did you serve in (SWAT, Detective, Search and Rescue, etc)?

Basic Health Information

Primary Care Provider:

Are you currently under medical care?

Yes

No

Please describe:

Are you currently taking any prescription medications?

Yes

No

If yes, list (optional)

Do you have any allergies?

Food

Medication

Environmental

None

If yes please describe:

Do you have any physical limitations or injuries that may affect participation?

Yes

No

If yes please describe:

Do you have any dietary preferences or restrictions?

Vegetarian

Vegan

Gluten-free

None

Mental Health and Wellness

Have you ever been diagnosed with a mental health condition?

Yes

No

Prefer not to say

If yes, specify:

Are you currently receiving counseling, therapy, or psychiatric care?

Yes

No

Have you ever been hospitalized for a mental health concern?

Yes

No

Prefer not to say

Do you currently experience any of the following? (check all that apply)

Have you experienced significant loss, trauma, or moral injury related to your work or service?

Yes

No

Prefer not to say

Do you have a support system you can rely on (family, friends, peers, faith, etc.)?

Yes

No

Prefer not to say

WELLNESS PROGRAM APPLICATION

The Restorative Path

Emergency Contact Information:

Demographics and Background

Military Service: Please answer these questions if you served in the military.

First Responder Experience: Please answer these questions if you are or have served as a first responder.

Basic Health Information

Mental Health and Wellness