Warrior Hope Network - Application

Warrior Hope Network - Application

Today's Date*

First Name*

Middle Name (if applicablle)

Last Name*

Phone*

Phone

Preferred Method of Contact

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Address*

City, State, Zip Code*

Date of Birth*

Gender

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Height (ft)

Weight (lbs)

Disability Rating (if applicable)

Race

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Ethnicity

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Service Dog?

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Caregiver?

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Marital Status

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Spouse First, Middle, Last Name (if applicable)

Spouse Age (if applicable)

Has your spouse ever served in the military?

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If yes, what branch?

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Children?

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If yes, how many?

Do you have a DD214 that you can provide?

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May Warrior Hope Network discuss with your spouse or significant other anything pertaining to your treatments, process, medical history, legal issues pertaining to PTS/TBI and/or anything our staff might think is important for us or your spouse to know?

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Emergency Contact: First, Middle, Last Name*

Emergency Contact: Relationship*

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Emergency Contact: Phone *

Phone

Emergency Contact: Email*

Are you currently employed?

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If yes, what is your job title?

If yes, what is your job description?

Are you satisfied with where you are in life at this current time?

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If no, please explain.

How has your sacrifice in quality of life affected your life, and that of your family?

Please provide a brief description of your military service.

Were you wounded/injured or otherwise hurt during you time in the military?

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If yes, please list any and all injuries incurred while in the military.

Are you still experiencing any problems or have concerns related to these injuries?

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If yes, please explain.

During your time in the military did you receive care for combat stress or a mental health problem/concern?

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If yes, please explain.

During your time in the military, did any of the following happen to you? (Select all that apply)

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If you selected "Blast, explosion, burn pit exposure (e.g. IED, RPG, EFP, land mine, grenade)" estimate your distance from the closest blast, explosion, and or burn pit.

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If you selected "Fragment wound or bullet wound" list location(s) on body.

If you selected "New allergic reactions (drug, food, and/or environment)" please explain.

Over the past month have you experienced any stressors that are a cause of significant concern or make it difficult for you to do work, take care of things at home, or get along with other people (e.g. serious conflicts with others, relationship problems, or legal, disciplinary and/or financial problems)?

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If yes, please list and briefly explain those stressors and/or any that weren't previously mentioned.

Are you worried about your health because you believe you were exposed to something in the environment while deployed (i.e. burn pits)?

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If yes, please explain.

Do you think you were wxposed to any chemical, biological, or radiological warfare agents during your deployments?

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If yes, please explain.

Please describe your life after military service (i.e., date you were discharged, type of discharge, reason for discharge, how many years of service completed, jobs held, treatments recieved, family life, stressors, health concerna, anything you feel is important for our team to know, please be as descriptive as possible).

Please select the services you are requesting.*

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