DEPARTMENT OF VETERANS AFFAIRS
Trauma Recovery Program
Palo Alto Health Care System
795 Willow Road
Menlo Park, CA 94025
In reply refer to:
Dear Colleague:
Thank you for your interest in the Trauma Recovery Program, the PTSD residential rehabilitation treatment
program at the VA Palo Alto Health Care System. Enclosed, please find the referral packet for admission
of men and women to our residential treatment programs.
The Trauma Recovery Program, located at the Menlo Park Division of the VA Palo Alto Health Care
System, provides state-of-the-art diagnostic assessment and evaluation of male and female veterans and
active duty personnel experiencing war zone related stress, sexual trauma while serving in the military, or
other traumatic events experienced during military service. The Women’s Trauma Recovery Program is a
10 bed facility opened in 1992 to provide women an opportunity for gender specific residential treatment for
PTSD located in a building designated specifically for the treatment of women. The Men’s Trauma
Recovery Program is a 40 bed facility originally opened in 1978 for the treatment of men with military
related PTSD. All individuals are admitted for a period of approximately 60 to 90 days; this timeframe can
be adjusted based on the individual’s clinical or personal needs. All admissions are scheduled on a rolling
basis.
The mission of the Trauma Recovery Program is to restore individuals with military-related post traumatic
stress disorder (PTSD) to their highest level of functioning and to promote their reintegration into their
communities and reconnection with their families and loved ones. This mission is accomplished through
cognitive behavioral therapy in the context of a therapeutic milieu with adherence to clinical practice
guidelines and utilization of evidenced-based treatments to the fullest extent possible. Residents spend 5-8
hours a day in group therapy learning skills in such areas as anger management, affect tolerance,
communication, health issues, and harm reduction. Participation in a Cognitive Processing Therapy group
is determined on an individual basis as is clinically appropriate. Participation in this group may increase
length of stay. Additional therapeutic interventions include participation in recreational therapy, art therapy,
choral group, service dog training, parenting skills, family therapy, family open houses, biking group, gym
time, and swimming. Referrals for speech therapy, physical therapy, and other specialty medical services
are available if clinically indicated.
The Trauma Recovery Program is a voluntary program and we ask that all referred individuals be ready to
participate in active treatment for their PTSD. A copy of the Treatment Contract is enclosed which the
veteran or service member is required to sign as part of the application process. Please discuss these
treatment expectations with the individual you are referring prior to submitting an application. When
deciding whether to refer an individual to the Trauma Recovery Program, please keep the following
Admissions Criteria in mind:
Current problems are primarily due to military related PTSD or post-deployment adjustment difficulties;
Patients must be psychiatrically and medically suitable for admission to the residential rehabilitation level of
care and able to actively participate in and benefit from treatment in this setting;
Must be able to remain alcohol and illegal substance free during treatment at the program and not be actively
withdrawing from alcohol or illegal substances;
Off benzodiazepines for at least 5 days (medically/clinically appropriate exceptions are considered on a case
by case basis);
May be on prescribed opiates at standing doses for the purpose of managing stable chronic pain. Please
include a pain consult or other notes regarding the use of opiates with the application;
VAPATRP (rev. 10/5/09) Page 1
Must not have any outstanding legal issues requiring the veteran or active duty service member to be absent
during any portion of the program or to be court ordered specifically to this program;
For active duty service members: Must be assigned or attached to a Military Medical Command (e.g.
Wounded Warrior Battalion, Warrior Transition Unit, medical hold unit, etc.).
Referral Process: After an interdisciplinary review of the application, the Admissions Coordinator will notify
the referring clinician regarding any further information needed to process the application, acceptance into
the program, or recommendations and reasons if the veteran or service member is found not to be
appropriate for this program at this time. As directed by the Uniform Health Services Guidelines, all
individuals must now receive a mental health evaluation within 7 days of discharge. You will be contacted
by a clinician from the Trauma Recovery Program to schedule this appointment.
Please submit the following documents to the Admissions Coordinator at the address below, in order for the
veteran or service member to be considered for admission:
1. Referral Information packet – completed by the referring clinician, NOT the applicant
2. A signed Treatment Agreement
3. A copy of DD214 (if a veteran)
4. If Active Duty, please include a copy of attachment orders for Military Medical Command
5. Please attach a current medication list to all applications
Applications can be faxed to (650) 617-2686 or mailed to:
Admissions Coordinator (352/117)
Trauma Recovery Program
VA Palo Alto Health Care System
795 Willow Road
Menlo Park, CA 94025
If you have questions regarding referrals, please call:
Men’s Trauma Recovery Program Admissions Coordinator
Kristen Marchak, LSW
(650) 614-9997 ext. 24692.
Women’s Trauma Recovery Program Admissions Coordinator
Marion Gautschi, MSW
(650) 614-9997 ext. 22843
VAPATRP (rev. 10/5/09) Page 2
VA Palo Alto Health Care System
Trauma Recovery Program
Referral Application
Name of Referring Clinician: VISN#: Clinician Phone:
( ) -
Agency/Organization: Clinician FAX:
( ) -
Clinician Address: Clinician Email:
Name of Applicant: Applicant SSN: Applicant DOB: Gender:
______ - ______ - ______ ____ /____ /____ Male
Female
Applicant Address: Applicant Phone:
Home ( ) -
Cell ( ) -
Ethnicity: Marital Status: Active Duty Veteran
Asian / Pacific Islander Never Married If Veteran -- Branch of Service:
African American Married Army Navy
Hispanic / Latino American Domestic Partner Air Force Marines
Caucasian Separated Coast Guard
Native American Divorced Service Connection:
Mixed Ethnicity Widowed Yes No If Yes, then
________________ # Children living with you: ____% For:_________________
Other (list)
Service Dates: Warzone Dates, if Military Jobs:
From: To: applicable:
/ / / / From: To: Highest Rank:
/ / / /
Theater: POW: Badges/Medals: Disciplinary: Discharge:
Korea Desert Storm Yes _____________ Article 15 Honorable
Vietnam Iraqi Freedom No _____________ Court Marshal General
Panama Afghanistan _____________ Other Medical
Grenada Other Other
If Active Duty, Guard or Reservist; Please complete the following:
Branch of Component: Current Service Status: Service Entry Date
Service: National Guard Active Duty (currently)
Army Reserve Retired ETS
Air Force Status: Date of Retirement:
Navy Activated TDRL
Marine Corps Drilling (Weekend) PDRL Release from Active Duty
Coast Guard IRR
Separated
Parent Command & POC & Phone Number
In Process of Discharge ETS MEB Limited Duty Admin Sep Other:
Anticipated date of separation (if known): Status of MED/PEB:
VAPATRP (rev. 10/5/09) Page 3
Current Psychiatric Diagnoses:
Axis I:
Axis II:
Axis III:
Please describe your clinical experience with this applicant. What is(are) the applicant’s trauma issues and how
are they being addressed in treatment? Please describe any other issues that are also being addressed in
treatment.
Why are you recommending inpatient rather than continued outpatient treatment?
Psychiatric History:
Does the applicant have a history of suicidal ideation? No Yes
Has the applicant made suicide attempts? No Yes Dates: _________________________________
Does the applicant have a history of self harm behaviors (cutting/burning self, eating disorders, etc.) ?
No Yes Dates:______________________________
Does the applicant have a history of homicidal ideation or assault? No Yes Dates:___________________
Does the applicant have a history of psychosis? No Yes Dates:________________________________
(Please describe the history of psychosis, suicidal/homicidal ideation, and self harm behaviors)
Traumatic Brain Injury History, if applicable:
Please attach a copy of any neuropsychological evaluation that was performed
Type of injury (e.g., blast, blunt injury, MVA, fall, etc.)
Date of event: Loss of consciousness: Yes No If yes, duration:
Post-traumatic amnesia: Yes No If yes, duration:
Describe other acute symptoms, or markers of severity:
Were there multiple events of TBI? Yes No If yes, number:
VAPATRP (rev. 10/5/09) Page 4
Substance Abuse History
Has the applicant abused: Alcohol Illegal Drugs Medications ______________________________
Drug Use (more than 10 Number months # times per week Treatment?
times in a month) since last use during last use
DATE:
Alcohol Yes No Inpt Outpt
Amphetamines Yes No Inpt Outpt
Barbiturates Yes No Inpt Outpt
Cannabis Yes No Inpt Outpt
Cocaine Yes No Inpt Outpt
Hallucinogens Yes No Inpt Outpt
Opiates (Heroin) Yes No Inpt Outpt
PCP Yes No Inpt Outpt
Prescription Abuse Yes No Inpt Outpt
Other: Yes No Inpt Outpt
Comments:
Legal History
Does the applicant have any outstanding legal issues (eg. court dates, warrants, court martial, etc)?
No Yes (Please describe)
Has the applicant been incarcerated? No Yes (Please describe)
Is the applicant currently on probation/parole? No Yes (Please describe)
Is the applicant a registered sex offender? No Yes (Please describe)
Additional Legal Information:
Personal History
Pre-Military history of disruptive or antisocial behavior? No Yes
History of violent acting out or antisocial behavior? No Yes
Victim of sexual assault? No Yes
Victim of domestic violence? No Yes
Family & Relationship Status
Are there minor children in the applicant’s care? No Yes
Can arrangements for care of children be made while applicant is hospitalized? No Yes
Will family be able to meet financial obligations while applicant is in care? No Yes
VAPATRP (rev. 10/5/09) Page 5
Transition Plan From Trauma Recovery Program to Outpatient Care
What are the circumstances of the applicant’s current residence? (i.e. lives alone, with others,
temporary/permanent residence, renting, owns, etc..)
Where will the veteran reside after discharge from the program?
Who will follow the applicant for outpatient mental health?
Who will follow the applicant for medical issues?
Primary Care Provider Address Email Phone
Therapist Address Email Phone
Psychiatrist Address Email Phone
Case Manger Address Email Phone
Other Address Email Phone
Is there a possibility that the applicant is currently pregnant? No Yes
Please attach a current complete medication list to all applications
If the applicant is treated by a provider outside of the VA system please attach the following:
History & Physical
Notes from theater, Medivac flight note, etc.
MD progress notes. If patient has fractures include ortho note with weight bearing status and any other
restrictions
Include notes from specialty services (i.e. neurosurgery, neurology, ID, plastics, ophthalmology)
Recent therapy notes from OT, PT & SLP
Neuropsychology testing performed
Psychosocial assessment
VAPATRP (rev. 10/5/09) Page 6
VAPAHCS TRAUMA RECOVERY PROGRAM INITIAL TREATMENT AGREEMENT
1. I agree to participate in and attend all scheduled groups and activities and to adhere to all aspects of my individual
treatment plan, including but not limited to prescribed medications, dietary restrictions, volunteer activities, and exercise
and recreation programs.
2. I understand that I cannot be admitted to the program while under the influence of alcohol, illegal substances or any
substance other than prescribed medications.
3. I understand that I am expected to disclose all prescribed and non-prescribed medications to my referring provider during
the application process. Unless a clinical exception has been made, at least 5 days abstinence from benzodiazepines is
required prior to admission. If I am not sure, I will ask my referring provider, for more information.
4. I understand that substance use is not compatible with treatment at the Trauma Recovery Program and will result in my
discharge from the program. I understand that Alcometer/Breathalyzer tests and random drug screens are part of the
treatment program.
5. I understand that physical violence, verbal abuse or threats of violence will be grounds for my discharge from the program.
6. I will not bring weapons or contraband to the program and will not store weapons or contraband in my hospital bedroom,
vehicle or on grounds during the course of my stay in the program.
7. If admitted, I agree to a search of my belongings (which may include vehicles) for safety concerns and contraband. If I
refuse I understand that I may be denied admission or be discharged.
8. I understand that while I am an inpatient at the Trauma Recovery Program, there are some restrictions on when I can leave
the hospital grounds. I will be issued a program manual which explains this and other program policies.
I have read the Treatment Agreement. I understand the described guidelines, endorse them, and will abide by them if accepted into
the program.
______________________________________________________________________________
Applicant's signature Date
I have reviewed and discussed these treatment expectations with the applicant and support this application to the Trauma Recovery
Program. I will provide follow-up care myself within seven days after discharge or have identified an alternate clinician who can
and will provide this information to the Admissions Coordinator at the Trauma Recovery Program.
______________________________________________________________________________
Referring clinician's signature Date
VAPATRP (rev. 10/5/09) Page 7