Warrior Application by ashrafp


									     The California Transition Center for Care of Combat Veterans:
                          The Pathway Home

                  OIF/OEF Warriors Interested in Applying
Dear Warrior,

At The Pathway Home we understand that many warriors returning from Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) have issues and
concerns related to combat stress and are thinking about seeking help. We are
committed to working with you toward getting the help you want and need. Please
do your best to complete the following information. Please identify all military and
civilian health care providers you have seen in regards to your health problems and
treatments you have received for medical and psychological stress. A staff member
from The Pathway Home will contact you by phone or email within one business
day [Monday – Friday excluding holidays] after receiving your email. If you have
any questions, please contact the admissions coordinator by telephone (707) 948-
3045 or email: Deborah.Young@thepathwayhome.org. We’re glad that you are
interested and we look forward to hearing from you!

If you find yourself in a crisis situation, please call 1-800-273-8255 for immediate
assistance, after the line is answered, press #1 to speak with a counselor trained to
help warriors.

Thank you,

The Pathway Home Staff

Please describe how you have been feeling and the issues you have been struggling
with during the past 6 months.

                                  The Pathway Home 1
Please list the name, agency, address and phone number for all of your medical and
mental health care providers:

Providers Name(s):                   Address                      Phone

Date(s) of Treatment:

Reason(s) for Treatment:

Please check:              Individual Therapy       Group Therapy          Medication

Was treatment helpful?      Yes         No

If not, why not? What could have made it more helpful?

                                  The Pathway Home 2
             The California Transition Center for Care of Combat Veterans:
                                  The Pathway Home
                             APPLICANT’S PERSONAL INFORMATION

Applicant Name:


Mailing Address:

Home Phone:                                                 Cell:

Place of Birth:                                             DOB:

Gender:           Male     Female             Legal Changes Pending:            Yes       No

 Living Arrangements:       Alone      With Family      With Friends       Roommate       Homeless

                            With spouse/partner      Currently Active Duty

             Ethnicity                                                Marital Status

             African American                                         Never Married

             Asian/ Pacific Islander                                  Married

             Caucasian                                                Domestic Partner

             Hispanic / Latino American                               Separated

             Native American                                          Divorced –
                                                                      If yes, how long?
             Other (please list)                                      Widowed –
                                                                      If yes, how long?

  Children’s Names                                                  Age      Do you have physical
                                                                             and legal custody?
                                                                                Yes             No
                                                                                  Yes          No
                                                                                  Yes          No

                                          The Pathway Home 3
                                          MILITARY INFORMATION
                                          Please send a copy of DD-214

Military Installation (if Active Duty):

Reserve/National Guard Assigned Station or Armory:

Military Address:

Phone:                                                       Fax:

Service Entry Date:                                 Discharge Date:

War Zone Date(s):

Military Jobs:


Service Connected:           Yes          No   Percentage:            Total Income:

Copy of DD-214 Attached?           Yes         No

         Branch of Service                     Theatre                      Decoration(s)
         Army                                  Afghanistan                  Purple Heart

         Air Force                             Iraq Freedom                 CIB

         Navy                                  Grenada                      CAB

         Marines                               Desert Storm                 Other

         Coast Guard                           Panama

             Disciplinary                      Considered For:              POW:
             Article 15                        Medical discharge            Yes

             Court Martial                     Retirement                   No

                                               Return to duty

                                          The Pathway Home 4
                          PROBLEM CHECKLIST

                 Please check symptoms you are experiencing

Numbness                           Denial or shock            Flashbacks

Anger                              Despair                    Sadness

Concentration Problems             Memory Problems            Jumpy

Work or School Problems            Irritability               Frustration

Excess Smoking                     Stomach Upset              Sleeping Problems

Headaches                          Suicidal Thoughts          Avoiding People

Withdrawal                         Nervous                    Alcohol/Drug Abuse

Startle Easily                     Intrusive Thoughts         Grief

Fear                               Feelings of Loss           Feeling Detached

Nightmares                         On Guard                   Overeating

Hopelessness                       Helplessness               Avoiding Places

Aggressive behavior                Difficulty Eating          Avoiding Intimacy

Hallucinations                     Anxiety                    Panic Attacks

                           The Pathway Home 5

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